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Frontispiece. 


Plate  i. 


K  - 


/ 


3.      'iv.    .  \ 


\ 


I.  Bacillus  of  Tetanus,  with  Spores.  2.  Gonococci  in  Gonorrhoeal  Pus  (aniline,  methyl-violet). 
3.  Tubercle  Bacilli  in  Sputum  (Ziegler).  4.  Hutchinson  Teeth.  5,  6.  Radial  Pulse-tracings  in 
Aneurysm  of  Right  Brachial  Artery  :  5,  left  radial  pulse ;  6,  right  radial  pulse. 


Sauntrrrs'  IMcto  ^tti  Scries 


A   MANUAL  OF 
MODERN 

SURGERY 

GENERAL  AND  OPERATIVE 

BY 

JOHN  CHALMERS  DaCOSTA,  M.D., 

DEMONSTRATOR     OF     SURGERY,     JEFFERSON     MEDICAL     COLLEGE,     PHILADELPHIA; 
CHIEF    ASSISTANT  SURGEON,  JEFFERSON    MEDICAL    COLLEGE    HOSPITAL,  ETC. 


WITH    188    ILLUSTRATIONS    IN    THE   TEXT 

AND   13   FULL-PAGE    PLATES    IN    COLORS    AND   TINTS, 

AGGREGATING  276    SEPARAXE   FIGURES 


W.    B.    SAUNDERS 

925  Walnut   Street. 
1894. 


■P.i 


Copyright,  1894,  by 
W.    B.    SAUNDERS 


EUECTROTYPED    BY  PRESS   OF 

WESTCOTT  &  THOMSON,   PHILADA.  W.   B.   SAUNDERS,   PHILADA. 


o 

-J 


CO 

'Si- 
CD 


OS 

a. 


THIS   VOLUME   IS 
DEDICATED,    WITH    AFFECTIONATE   REGARDS,    TO 

DR.  ORVILLE    HORWITZ. 

THE   FELLOW-STUDENT,    THE   HOSPITAL   ASSOCIATE,    AND 
THE   TRUSTED    FRIEND    OF 

THE  AUTHOR. 


PREFACE. 


The  aim  of  this  Manual  is  to  present  in  clear  terms 
and  in  concise  form  the  fundamental  principles,  the  chief 
operations;  and  the  accepted  methods  of  modern  surgery. 
The  work  seeks  to  stand  between  the  complete  but  cumbrous 
text-book  and  the  incomplete  but  concentrated  compend. 

Obsolete  and  unessential  methods  have  been  excluded  in 
favor  of  the  living  and  the  essential.  There  has  been  no 
attempt  to  exploit  fanciful  theories  nor  to  defend  unprovable 
hypotheses,  but  rather  the  effort  has  been  to  present  the  sub- 
ject in  a  form  useful  alike  to  the  student  and  to  the  busy 
practitioner. 

The  opening  chapter  is  devoted  to  Bacteriology  because 
the  author  profoundly  believes  that  without  some  knowledge 
of  the  vital  principles  of  this  branch  of  science  the  vast  im- 
portance of  its  truths  will  be  ill-appreciated,  and  there  will 
be  inevitable  failure  in  the  application  of  aseptic  and  anti- 
septic methods. 

Ophthalmology,  gynecology,  rhinology,  otology,  and  lar- 
yngology have  not  been  considered,  because  of  the  obvious 
fact  that  in  the  advanced  state  of  specialized  science  only  the 
specialist  is  competent  to  write  upon  each  of  these  branches. 

In  Orthopedic  Surgery  are  discussed  those  conditions 
which  must  in  the  very  nature  of  things  often  be  cared  for 
by  the  surgeon  or  the  general  practitioner  (such  as  hip-joint 
disease,  club-foot,  Pott's  disease  of  the  spine,  flat-foot,  etc.). 
The  limited  space  at  command  precluded  the  introduction  of 
a  special  division  on  diseases  of  the  female  breast.  A  large 
amount  of  space  has  been  devoted  to  Fractures  and  Dis- 
locations, the  enormous  practical  importance  of  these  sub- 
jects calling  for  their  full  discussion.     Operative  Surgery  is 

3 


4  PREFACE. 

considered  in  separate  sections,  the  most  important  pro- 
cedures being  fully  described,  giving  also  the  instruments 
necessary,  and  the  positions  assumed  by  patient  and  operator. 
This  method  has  been  adopted  to  fit  the  work  for  use  in  sur- 
gical laboratories. 

Many  systems,  manuals,  monographs,  lectures,  and  journal 
articles  have  been  consulted,  and  credit  has  been  given  in 
the  text  for  statements  and  quotations.  Special  acknowl- 
edgment is  due  to  the  American  Text-Book  of  Surgery^ 
edited  by  Keen  and  White ;  to  the  surgical  works  of 
Ashurst,  Agnew,  the  elder  Gross,  Duplay  and  Reclus, 
Esmarch,  Albert  Koenig,  Wyeth,  and  Bryant ;  to  the  Man- 
ual of  Surgery  edited  by  Treves  ;  to  the  International  En- 
cyclop(Bdia  of  Surgery  edited  by  Ashurst ;  to  the  Surgical 
Pathology  of  Billroth  and  of  Bowlby ;  to  the  Diagnosis  of  E. 
Pearce  Gould ;  to  the  Surgical  Dictionary  of  Heath ;  to  the 
Rest  and  Pain  of  Hilton;  to  the  works  on  operative  sur- 
gery of  Barker,  Jacobson,  Treves,  Stephen  Smith,  and  Joseph 
Bell ;  to  the  Minor  Surgery  of  Wharton ;  to  the  dictionary 
of  Foster  and  of  Gould  ;  to  the  Principles  of  S^irgery  of  Senn; 
to  the  orthopedic  writings  of  Sayre ;  to  the  work  on  Diseases 
of  the  Male  Generative  Organs  of  Jacobson ;  to  the  System 
of  Genito-nrinary  Diseases  edited  by  Morrow ;  and  to  the 
treatises  on  Fractures  and  Dislocations  of  Sir  Astley  Cooper, 
Malgaigne,  Hamilton,  Stimson,  and  T.  Pickering  Pick. 

The  Author  returns  his  thanks  to  the  numerous  writers 
who  courteously  authorized  the  reproduction  of  special 
illustrations,  and  particularly  to  Professors  Keen  and  White 
for  their  free  permission  to  draw  upon  the  American  Text- 
Book  of  Surgery,  from  which  a  number  of  pictures  have  been 
taken,  distinctively  those  referring  to  Bandaging;  to  Mr. 
John  Vansant  for  the  great  amount  of  labor  so  ably  and 
cheerfully  performed ;  and  to  Dr.  Howard  De  Honey  for 
the  preparation  of  the  Index. 

2050  Locust  Street,  Philadelphia, 
October,  1894. 


CONTENTS. 


PAGE 

I.  Bacteriology 17 

^licro-orgaiiisms.  Microbes,  or  Bacteria,  17:  P'orms  of  Bacteria,  19; 
Multiplication  of  Bacteria,  21 ;  Life  Conditions  of  Bacteria,  22;  Effect 
of  Heat  and  Cold  on  Bacteria,  23 ;  Chemical  Germicides,  24 ;  Distribu- 
tion of  Microbes,  24 ;  Koch's  Circuit,  25 ;  Toxalbumins  and  Toxines, 
26;  Ptomaines,  27 ;  Leucomaines,  27;  Antitoxines,  27;  Phagocytes, 
28 ;  Protective  and  Preventive  Inoculations,  29 ;  Antagonistic  Microbes, 
30;  Mixed  Infection,  30;  Placental  Transmission,  30.  Special  Sur- 
gical Microbes,  31  :  Other  Surgical  Microbes,  32. 

II.  Inflammation 33 

Definition,  33 ;  Vascular  and  Circulatory  Changes,  -^t^  ;  Active  Hyper- 
semia,  ^t^  ;  Retardation  of  the  Circulation,  34 ;  Oscillation  and  Stagna- 
tion, 36 ;  Exudation  of  Fluids,  36 ;  Diapedesis  or  Migration,  37 ; 
Changes  in  the  Perivascular  Tissues,  38 ;  Classification  of  Inflamma- 
tions, 39;  Ejy^nsion  of  Inflammation,  40;  Terminations  of  Inflam- 
mation, 41 ;  Causes  of  Inflammation,  41 ;  Symptoms  of  Inflammation, 
42;  Constitutional  Symptoms  of  Inflammation,  47  ;  Treatment  of  In- 
flammation, 47 ;  Local  Treatment  of  Inflammation,  48 ;  Constitu- 
tional Treatment  of  Inflammation,  60. 

III.  Repair 73 

Healing  by  First  Intention,  73;  Healing  by  Second  Intention,  74;  Heal- 
ing by  Third  Intention,  75  ;   Cell-division,  76. 

IV.  Surgical  Fevers 77 

Types  of  Fever,  78  :  Sthenic,  78 ;  Asthenic,  78 ;  Nervous,  79.  Trau- 
matic Fevers,  80 : — Primaiy  Wound-fever :  a.  Aseptic  Fever,  b. 
Traumatic  or  Surgical  Fever,  80;  Secondary  ^Yound-fever :  Sup- 
purative Fever,  81. 

V.  Terminations  of  Inflammation 81 

Effusion  of  Serum,  8i ;  Effusion  of  Lymph,  82;  Suppuration,  84;  Forms 

of  Pus,  85.    Abscesses,  88  :  Forms  of  Abscesses,  90;  Acute  Abscess,  91, 

VI.  Ulceration  and  Fistula loi 

Necrosis,   102;    Classification  of  Ulcers,  102;    Acute  Ulcer  of  the  Leg, 

103;  Chronic  Ulcer  of  the  Leg,  104;  Complications  of  Ulcers,  105; 
Ulcers  in  any  Region,  1075  Fistula,  108;  Sinus,  108, 

5 


6  CONTENTS. 

PAGE 

VII.  Mortification  or  Gangrene 109 

Classification,  109  ;  Dry  or  Chronic  Gangrene  (Pott's  Gangrene),  iio; 
Senile  Gangrene,  iii;  Moist  or  Acute  Gangrene,  113.  Septic  Gaii- 
grene,  114:  a.  Traumatic  Gangrene,  115,  b.  Hospital  Gangrene,  115. 
Special  Forms  of  Gangrene,  116:  a,  Symmetrical  Gangrene,  116;  b. 
Diabetic  Gangrene,  117;  c,  Gangrene  from  Ergotism,  117;  d,  Gan- 
grene from  Frost-bite,  118;  e,  Noma,  or  Cancrum  Oris,  118;  Slough- 
ing, 119;  Phagedsena,  119;  Decubital  Gangrene,  or  Bed-sore  (Decu- 
bitus), 1 20  5  Rules  for  Amputation  in  Gangrene,   121. 

VIII.  Thrombosis  and  Embolism 122 

IX.  Septicaemia  AND  Pyaemia 125 

Septicccniia,  125;  Sapraemia,  or  Septic  Intoxication,  125;  Septic  Infection, 
or  True  Septicaemia,  126.     Pya:mia,  127. 

X.  Erysipelas  (St.  Anthony's  Fire) 129 

Forms  of  Erysipelas,  130 ;  Clinical  Forms,  130;   Cutaneous  Erysipelas, 

130;  Cellulo-cutaneous  or  Phlegmonous  Erysipelas,  131 ;  CelluUtis,  132. 

XI.  Tetanus,  or   Lockjaw 133 

Acute,  133;  Chronic,  134. 

XII.  Tuberculosis  and  Scrofula 137 

Bacillus  of  Tubercle,   138;    Tubercular    Infection,   140;    Scrofula,   141 ; 

Tuberculous  Abscess,  142;  Tuberculosis  of  the  Skin,  142;  Anatomi- 
cal Tubercle,  142;  Scrofulodermata,  or  Scrofulous  Gummata,  142; 
Tuberculosis  of  Subcutaneous  Connective  Tissue,  143;  Tuberculosis  of 
the  Alimentaiy  Canal,  143;  Intestinal  Tuberculosis,  143;  Peritoneal 
Tuberculosis,  144;  Tuberculosis  of  the  Brain,  144;  Tuberculous  Dis- 
ease of  the  Joints,  144;  Tuberculosis  of  Lymphatic  Glands,  144; 
Diagnosis,  Prognosis,  and  Treatment  of  Tuberculosis,  145 ;  Koch's 
Tuberculin,  146. 

XIII.  Rickets i47 

XIV.  Contusions  and  Wounds 148 

Contusions,  148  ;  Wounds,  149  ;  Local  Phenomena  of  Wounds,  149  ;  Con- 
stitutional Condition  of  Wounds,  150;  Treatment  of  Wounds,  151 ;  In- 
cised Wounds,  153;  Lacerated  and  Contused  Wounds,  153;  Punctured 
Wounds,  154;  Gunshot  Wounds,  154;  Poisoned  Wounds,  156;  Septic 
Wounds,  156;  Dissection-wounds,  156;  Malignant  CEdema  or  Gan- 
grenous Emphysema,  157;  Stings  and  Bites  of  Insects  and  Reptiles, 
157;  Anthrax,  160;  Hydrophobia,  Rabies,  or  Lyssa,  162;  Glanders, 
Farcy,  or  Equinia,  163;  Actinomycosis,  164. 


CONTENTS.  7 

PAGE 

XV.  Syphilis 165 

Definition,  165;  Transmission  of  Syphilis,  166;  Syphilitic  Stages,  167; 
Syphilitic  Peiiods,  167;  Primary  Syphihs,  167;  Initial  Lesions,  168; 
Mixed  Infection  of  Chancre  and  Chancroid,  168 ;  Syphilitic  Bubo,  171 ; 
General  Syphilis,  172;  Secondary  Syphilis,  172.  Syphilitic  Skin  Dis- 
eases, 172:  Forms  of  Eruption,  173.  Aftections  of  the  Mucous  Mem- 
branes, 175;  Affections  of  the  Hair,  176;  Affections  of  the  Nails,  176; 
Affections  of  the  Ear,  176;  Affections  of  the  Bones  and  Joints,  176; 
Affections  of  the  Eye,  177;  Affections  of  the  Testes,  177;  Intermediate 
Period,  177;  Tertiary  Syphihs,  178;  Treatment  of  Primary  Stage,  180; 
Treatment  of  Secondary  Stage,  181  ;  Acute  PtyaHsm,  or  Salivation, 
184;  Treatment  of  Tertiar>-  Stage,  187;  Hereditary  Syphilis,  188. 

XVI.  Tumors,  or  Morbid  Growths 191 

Neoplasms,  191  ;  Classes  of  Tumors,  192;  Causes,  193;  Malignant  and 
Innocent  or  Benign  Tumors,  194;  Classification,  195.  Innocent  Con- 
nective-tissue Tumors,  196:  Lipomata,  196;  Fibromata,  197;  Chon- 
dromata,  199;  Osteomata,  200;  Odontomata,  201;  Myxomata,  202; 
Lymphomata,  203 ;  Myomata,  204 ;  Neuromata,  207 ;  Angeiomata, 
208;  Lymphangeiomata,  209.  Malignant  Comiective-tissue  Tumors, 
or  Sarcomata,  2IO.  Injiocent  Epithelial  Tuviors,  215.  Papillomata, 
or  Warts,  2j^.  Adenomata,  216.  Malignant  Epithelial  Tumors, 
Carcinof?iata,  or  Cancers,  217-  Epitheliomata,  219;  Rodent  Ulcer, 
219;  Spheroidal-celled  Carcinomata,  220 ;  Cylindrical-celled  Carcino- 
mata,  221.  Cysts,  222:  Sebaceous  Cysts,  222;  Dermoid  Cysts,  223 ; 
Hydatid  Cysts,  223. 

XVII.  Diseases  and  In7URIes  of  the  Heart  and  Vessels  ....    224 
Heart  and  Pericardium^  224:  Wounds  and  Injuries,  224;  Phlebitis,  or 

Inflammation  of  a  Vein,  225  ;  Varicose  Veins,  or  Varix,  225  ;  Nsevus, 
227;  Arteritis,  227.  Aneioysm,  229:  Forms  of  Aneurysm,  230; 
Causes  of  Aneun,'sm,  233  ;  Constituent  Parts  of  xA.neurysm,  233  ;  Symp- 
toms of  Aneurysm,  234 ;  Diagnosis  of  Aneur}-sm,  234 ;  Treatment  of 
Aneurysm,  235  Arterio-venous  Aneurysm,  241.  Citsoid  Aneurysm, 
or  Aneurysm  by  Anastomosis,  242.  Wounds  of  Arteries,  243.  (l) 
Hemorrhage,  or  Loss  of  Blood,  244 :  Hemorrhagic  Fever,  245 ; 
Hemostatic  Agents,  246;  Golden  Rules  for  Procedure  in  Primary 
Hemorrhage,  249 ;  Reactionary  or  Recurrent  Hemorrhage,  258 ;  Sec- 
ondary Hemorrhage  258.  (2)  Operations  on  the  Vascular  Sys- 
tem, 260:  Paracentesis  Auriculi,  260;  Paracentesis  Pericardii,  260; 
Operation  for  Varix  of  Leg,  260;  Open  Operation  for  Vancocele,  261 ; 
Subcutaneous  Ligature  for  Varicocele,  261 ;  Phlebotomy,  or  Venesec- 
tion, 262;  Transfusion  of  Blood,  263.     (3)  Ligation  of  Arteries 


8  CONTENTS. 

PAGE 

IN  Continuity,  265  :  Radial  Artery,  268 ;  Ulnar  Artery,  271 ;  Brachial 
Artery,  272;  Axillary  Artery,  274;  Subclavian  Artery,  277;  Region  of 
the  Neck,  278  ;  Common  Carotid  Artery,  280;  External  Carotid  Artery, 
283;  Internal  Carotid  Artery,  284;  Lingual  Artery,  285;  Dorsalis 
Pedis  Artery,  285 ;  Anterior  Tibial  Artery,  287 ;  Posterior  Tibial 
Artery,  289;  Popliteal  Artery,  290;  Femoral  Artery,  290;  Iliac 
Arteries,  293. 

XVIII.  Diseases  and  Injuries  of  Bones  and  Joints 295 

(i)  Diseases  of  the  Bones,  295  :  Atrophy  of  Bone,  295  ;  Hypertrophy  of 
Bone,  295  ;  Osteitis,  or  Inflammation  of  Bone,  295  ;  Chronic  Periostitis, 
298 ;  Osteoplastic  Periostitis,  298 ;  Abscess  of  Bone,  298 ;  Caries,  299 ; 
Necrosis,  301 ;  Acute  Diffuse  Osteo-myelitis,  303 ;  Acute  Epiphysitis, 
304;  Chronic  Osteo-myelitis,  305  ;  Osteo-malacia,  or  Mollities  Ossium, 
305.  (2)  Fractures,  306:  Definition,  306;  Varieties,  306;  Causes, 
311 ;  Symptoms,  314;  Varieties  of  Displacement,  315  ;  Diagnosis,  318; 
Complications  and  Consequences,  320;  Repair  of  Fractures,  320; 
Non-union  of  Fractures,  322;  Treatment  of  Fractures,  322.  Special 
Fractures:  Nasal  Bones,  328.  Superior  Maxillary  Fractures,  331. 
Fracture  of  Malar  Bone,  333.  Fracture  of  the  Zygomatic  Arch,  333. 
Fractures  of  Inferior  Maxillary  Bone,  333.  Fractures  of  Hyoid 
Bone,  335,  Fractui-e  of  Laryngeal  Cartilages,  336.  Fracture  of  the 
Ribs,  337  :  Fracture  of  Costal  Cartilages,  340.  Fracture  of  Sternum, 
341.  Fractures  of  the  Pelvis,  343:  Fractures  of  False  Pelvis,  343; 
Fractures  of  True  Pelvis,  344.  Fracture  of  Sacrum,  346.  Fractures 
of  Coccyx,  347.  Fracture  of  Clavicle,  348 :  Fractures  of  Shaft  of 
Clavicle,  348;  Fracture  of  Acromial  End  of  Clavicle,  351;  Fracture 
of  Sternal  End  of  Clavicle,  352.  Fracture  of  Scapula,  352 :  Frac- 
tures of  Neck  of  Scapula,  353  ;  Fractures  of  Glenoid  Cavity  of  Scapula, 
353 ;  Fracture  of  Acromion  Process  of  Scapula,  353 ;  Fracture  of 
Coracoid  Process  of  Scapula,  354.  Fractures  of  Humerus,  354 : 
Fracture  of  Anatomical  Neck  of  Humerus,  354;  Fractures  of  Surgical 
Neck  of  Humerus,  356;  Longitudinal  and  Oblique  Fracture  of  Head 
of  Humerus,  357;  Separation  of  Upper  Epiphysis  of  Humerus,  358; 
Fracture  of  Shaft  of  Humerus,  359;  Fractures  of  Lower  Extremity  of 
Humerus,  360;  Fracture  of  External  Condyle  of  Humerus,  360; 
Fracture  of  Inner  Epicondyle  of  Humerus,  360;  Fracture  of  Internal 
Condyle  of  Humerus,  361 ;  Fracture  at  Base  of  Condyles  of  Humerus, 
361 ;  T-Fracture  of  Humerus,  361 ;  Fractures  in  or  near  Elbow-joint, 
361 ;  Epiphyseal  Separation  of  Humerus,  362.  Fractures  of  Ulna, 
363 :  Fracture  of  Coronoid  Process  of  Ulna,  363 ;  Fracture  of 
Olecranon  Process  of  Ulna,  363  ;  Fracture  of  Shaft  of  Ulna,  364 ; 
Fracture  of  Styloid  Process  of  Ulna,  365.     Fractures  of  Radius,  365: 


CONTENTS.  9 


PAGE 


Fracture  of  Head  of  Radius,  365 ;  Fracture  of  Neck  of  Radius,  366 ; 
Fracture  of  Shaft  of  Radius,  366 ;  Fracture  of  Radius  above  Insertion 
of  Pronator  Radii  Teres  Muscle,  366;  Fracture  of  Radius  below  In- 
sertion of  Pronator  Radii  Teres  Muscle,  367;  Fracture  of  Shafts  of 
both  Bones  of  Forearm,  367 ;  Fracture  of  Lower  Extremity  of  Radius, 
368 ;  Fracture  of  Both  Radius  and  Ulna  near  Wrist,  370 ;  Separation 
of  Lower  Radial  Epiphysis,  370.  Fractures  of  Carpus,  371 :  Fracture 
of  Metacarpal  Bones,  371  ;  Fractures  of  Phalanges,  372.  Fracture  of 
Femur,  372:  Fractures  of  Upper  Extremity  of  Femur,  372;  Intra- 
capsular Fracture  of  Femur,  372;  Extracapsular  Fracture  of  Femur, 
379 ;  Fracture  of  Great  Trochanter,  380 ;  Separation  of  Upper  Epiphy- 
sis of  Femoral  Head,  381  ;  Separation  of  Epiphysis  of  Great  Tro- 
chanter, 381 ;  Fractures  of  Shaft  of  Femur,  381 ;  Fracture  of  Femur 
above  Condyles,  383 ;  Fracture  of  Femur  Separating  either  Condyle, 
384;  Longitudinal  Fractures  of  Femur,  385;  Separation  of  Lower 
Epiphysis  of  Femur,  385.  Fracture  of  Patella,  385:  Fracture  of 
Patella  by  Muscular  Action,  385  ;  Transverse  Fractures  of  Patella, 
386 ;  Fractures  of  Patella  by  Direct  Force,  387.  Fractures  of  Tibia, 
388:  Fractures  of  Upper  End  of  Tibia,  388;  Separation  of  Upper 
Epiphysis  of  Tibia,  389 ;  Fractures  of  Shaft  of  Tibia,  389 ;  Fractures 
of  Lower  End  of  Tibia  :  Fracture  of  Inner  Malleolus,  389 ;  Separation 
of  Lower  Epiphysis  of  Tibia,  390.  Fracture  of  Fibula,  390  :  Fractures 
of  Upper  Two-thirds  of  Fibula,  390;  Fractures  of  Lower  Third  of 
Fibula,  390;  Pott's  Fracture  of  Fibula,  391 ;  Fracture  of  Both  Bones 
of  Leg,  392.  Fractures  of  Bones  of  Foot,  393  :  Fractures  of  Meta- 
tarsal Bones,  395 ;  Fractures  of  Phalanges  of  Toes,  395.  (3)  Dis- 
eases OF  THE  Joints,  395 :  Synovitis,  395  :  Acute  Synovitis,  395 ; 
Chronic  Synovitis,  396.  Arthritis,  397  :  Tubercular  Arthritis,  398. 
Tuberculosis  of  Special  Joints,  400 :  Hip-joint,  400;  Knee-joint  Dis- 
ease, 407;  Ankle-joint  Disease,  409;  Shoulder-joint  Disease,  409; 
Elbow-joint  Disease,  410;  Wrist-joint  Disease,  410;  Septic  Arthritis, 
411;  Infective  Arthritis,  411  ;  Gonorrhoeal  Arthritis,  or  Gonorrhoeal 
Rheumatism,  412;  Rheumatic  Arthritis,  414;  Gouty  Arthritis,  415; 
Arthritis  Deformans,  416.  Charcot's  Disease,  419.  Hysterical  Joint,  420. 
Neuralgia  of  Joints,  421.  Articular  Wounds  and  Injuries,  422  :  Sprains, 
423.  Ankylosis,  425  :  False  or  Extra-articular  Ankylosis,  428.  Loose 
Bodies  in  Joints  (Floating  Cartilages),  428.  (4)  Luxations  or  Dislo- 
cations, 429  :  Traumatic  Dislocations,  430;  Spontaneous,  Pathological, 
and  Consecutive  Dislocations,  431 ;  Congenital  Dislocations,  431 ; 
Compound  Traumatic  Dislocations,  435  ;  Old  Traumatic  Dislocations, 
436.  Special  Trauviatic  Dislocations  :  LoTver  Jaiu,  436.  Dislocation 
of  the    Clavicle:    Sternal   End,   438;    Forward    Dislocation   of  the 


lO  CONTENTS. 

PAGE 

Clavicle,  438 ;  Backward  Dislocation  of  Clavicle,  439 ;  Upward  Dis- 
location of  Clavicle,  439;  Dislocation  of  Acromial  End  of  Clavicle, 
440.  Dislocation  of  Lower  Angle  of  Scapula,  440.  Dislocations  of 
Hiitnerus  {^Shoulder-joint^,  441.  Dislocation  of  Eliww-joint,  448: 
Dislocation  of  Both  Bones  of  Elbow  Forward,  449;  Lateral  Disloca- 
tions of  Both  Bones  of  Elbow,  449.  Dislocation  of  Ulna,  450.  Dis- 
location of  Radius  Forward,  450:  Dislocation  of  Radius  Backward, 
45 1  ;  Dislocation  of  Radius  Outward,  45 1  ;  Subluxation  of  Head  of 
Radius,  451.  Dislocations  of  Wrist,  452:  Backward  Dislocation  of 
Wrist,  453 ;  Forward  Dislocation  of  Wrist,  453 ;  Dislocation  at  Infe- 
rior Radio-ulnar  Articulation,  453.  Dislocations  of  Individual  Carpal 
Bones,  454.  Dislocations  of  Metacaipal  Bones,  454 :  Dislocation  at 
Metacarpo-phalangeal  Articulations,  454;  Dislocation  of  Metacarpo- 
phalangeal Joint  of  Thumb,  454.  Dislocations  of  Phalanges,  455. 
Dislocations  of  Ribs  and  Costal  Cartilages,  456.  Dislocations  of 
Sternum,  456.  Pelvic  Dislocations,  456,  Dislocations  of  Femur 
[Hip-joint),  457  :  Dislocation  of  Femur  on  Dorsum  of  Ilium,  457  ; 
Dislocation  of  Femur  into  Sciatic  Notch,  460;  Dislocation  of  Femur 
Downward  into  Obturator  Foramen,  461 ;  Dislocation  of  Femur 
into  Pubes,  462  ;  Anomalous  Dislocation  of  Hip,  462.  Dislocations  of 
Knee,  463 :  Dislocation  Forward  of  Knee-joint,  463 ;  Dislocation 
Backward  of  Knee-joint,  463 ;  Dislocation  Outward  of  Knee-joint, 
464 ;  Dislocation  Inward  of  Knee-joint,  464 ;  Lateral  Dislocations  of 
Knee-joint,  464;  Dislocation  of  Semilunar  Cartilages  of  Knee,  464. 
Dislocations  of  Fibula  :  Dislocation  at  Superior  Tibio-fibular  Articula- 
tion, 465.  Dislocations  of  Ankle-joint,  466 :  Lateral  Dislocations  of 
Ankle-joint,  466 ;  Antero-posterior  Dislocations  of  Ankle-joint,  467 ; 
Dislocation  Upward  of  Ankle-joint,  467.  Dislocation  of  Astragalus, 
468  :  Dislocation  of  Astragalus  Forward  or  Backward,  468 ;  Lateral 
and  Rotary  Dislocations  of  Astragalus,  468 ;  Sulmstragaloid  Disloca- 
tion, 469.  Dislocations  of  Other  Tarsal  Bones,  470.  Dislocations  of 
Metatarsal  Bones,  470.  Dislocations  of  Phalanges,  470.  (5)  Opera- 
tions ON  Bones,  470:  Osteotomy  470:  Osteotomy  for  Genu  Valgum, 
or  Knock-knee  (Macewen's  Operation),  471  ;  Osteotomy  for  Bent 
Tibia,  473  ;  Osteotomy  for  Faulty  Ankylosis  of  Hip-joint,  473 ;  Oste- 
otomy through  Neck  of  Femur,  473 ;  Osteotomy  of  Shaft  of  Femur 
below  Trochanters  (Gant's  Operation),  475 ;  Osteotomy  for  Faulty 
Ankylosis  of  Knee-joint,  475  ;  Osteotomy  for  Vicious  Union  of  Frac- 
ture, 476  ;  Osteotomy  for  Hallux  Valgus,  476 ;  Osteotomy  for  Talipes 
Equino-varus,  476;  Osteotomy  for  Talipes  Equinus  477;  Bone-graft- 
ing, or  Transplantation  (see  p.  303) ;  Osteotomy  and  Wiring  for 
Ununited  Fracture,  477.      Treves^    Operation  for  Caries  of  Lumbar 


CONTENTS.  1 1 

PAGE 

and  Last  Dorsal  Vertebnv,  479.  Aspiration  of  Joints,  480.  Ex- 
cision of  Bones  and  Joints,  481  :  Erosion,  or  Arthrectomy,  482;  Ex- 
cision of  Shoulder-joint,  483  ;  Excision  of  Elbow-joint,  487  ;  Excision 
of  Wrist-joint,  488 ;  Excision  of  Metacarpal  Bones  and  of  Phalanges, 
490;  Excision  of  Hip-joint,  491  ;  Excision  of  Ankle-joint,  495; 
Excision  of  Os  Calcis,  496 ;  Excision  of  Astragalus,  497 ;  Excision  of 
Metatarso-phalangeal  Articulation  of  Big  Toe,  497  ;  Excision  of  Meta- 
tarsal Bone  of  Big  Toe,  498;  Excision  of  Clavicle,  498;  Excision  of 
Scapula,  498 ;  Excision  of  Rib,  499 ;  Complete  Excision  of  One-half 
of  Upper  Jaw,  500 ;  Excision  of  One-half  of  Lower  Jaw,  502. 

XIX.  Diseases  and  Injuries  of  Muscles,  Tendons,  and  Burs^  .    .    .    503 
Myalgia,  or  Muscular  Rheumatism,  503 ;   Myositis,  505  ;  Hypertrophy  of 

Muscles,  505 ;  Atrophy  of  Muscles,  505 ;  Degeneration  of  Muscles, 
506 ;  Local  Ossification  and  Myositis  Ossificans,  506 ;  Tumors  of 
Muscles,  506;  Syphilis,  506;  Trichinosis,  506;  Wounds  and  Contu- 
sions of  Muscles,  507 ;  Strains  and  Ruptures  of  Muscles,  508 ;  Hernia 
of  Muscles,  509;  Contractions  of  Muscles,  509;  Dislocation  of  Ten- 
dons, 509;  Wounds  of  Tendons,  510;  Rupture  of  Tendons,  510. 
Tkecitis,  or  Tenosynovitis,  510:  Acute  Thecitis,  510;  Palmar  Abscess, 
511;  Chronic  Thecitis,  511.  Ganglia,  512.  Felon,  WTiitlow,  or 
Paronychia,  512.  Bursitis,  513.  Housemaid's  Knee,  514.  Bunion, 
514.  Operations  on  Tendons:  Tenotomy,  515:  Tenotomy  of  Tendo 
Achillis,  515  ;  Tendon-suture  and  Tendon-lengthening,  516. 

XX.  Orthopedic  Surgery 517 

Torticolhs,  518;  Dupuytren's  Contraction,  519  ;  Syndactylism  (Webbed 
Fingers),  520;  Polydactylism  (Supernumerar)^  Digits),  520;  Genu  Val- 
gum (Knock-knee),  520;  Genu  Varum  (Bow-legs),  521;  Talipes 
(Club-foot),  521;  Pes  Planus  (Flat-foot),  523;  Pes  Cavus  (Hollow- 
foot),  523;  Hallux  Valgus  or  Varus,  523;   Hammer-toe,  523. 

XXI.  Diseases  and  Injuries  of  Xerves 524 

(i)  Diseases  of  Nerves:  Neuritis,  or  Inflammation  of  a  Nerve,  524; 

Neuralgia,  525.  (2)  Wounds  and  Injuries  of  Nerves:  Section  of 
Nerves,  525;  Pressure  upon  Nerves,  526;  Contusions  of  Nerves,  527; 
Punctured  Wounds  of  Nerves,  527.  (3)  Operations  upon  Nerves  : 
Neurorrhaphy,  or  Nerve-suture,  527 ;  Neurectasy,  Neurotomy,  and 
Neurectomy,  52S ;  Stretching  of  Sciatic  Nerve,  529;  Neurectomy  of 
Infraorbital  Nerve,  529;  Neurectomy  of  Supraorbital  Nerv'e,  530. 

XXII.  Diseases  and  Injuries  of  the  Head 530 

(i)  Diseases  of  the  Head:  Anatomical  Regions  of  Head,  530;  Dis- 
eases of  Scalp,  534;  Diseases  of  Bones  of  Skull  (see  p.  295  et  seq.); 


1 2  CONTENTS. 

PAGE 

Microcephalus,  535.  Diseases  and  A/n  if  or  ma  lions  Involving  Brain  : 
Meningocele,  536;  Encephalocele,  536;  Hydrencephalocele,  536; 
Ilydroceplialus,  537;  Acute  Hydrocephalus,  537;  Chronic  Hydro- 
cephalus, 537.  (2)  Injuries  of  Head  :  Cephalhematoma,  537  ;  Scalp- 
wounds,  537  ;  Contusions  of  Head,  538;  Concussion  or  Laceration  of 
Brain,  538;  Compression  of  Brain,  540.  Intracranial  Hemorrhage : 
I,  Extradural  Hemorrhage,  542;  2,  Subdural  Hemorrhage,  543;  3, 
Cerebral  Hemorrhage,  543.  Rupture  of  a  Sinus,  544.  Fractures  of 
Skull,  544 :  Fractures  of  Vault,  545  ;  Fractures  of  Base,  546,  Wounds 
of  Brain,  549:  Gunshot  Wounds  of  Head,  550;  Fungus  Cerebri,  551 ; 
Traumatic  Inflammation  of  Brain,  551  ;  Pachymeningitis,  551 ;  Pachy- 
meningitis Interna,  552;  Leptomeningitis,  552;  Tuberculous  Menin- 
gitis, 553;  Acute  Traumatic  Leptomeningitis,  554;  Chronic  Lepto- 
meningitis, 556  ;  Abscess  of  Brain,  556 ;  Brain  Disease  from  Suppu- 
rative Ear  Disease,  558;  Cerebral  Abscess  from  Ear  Disease,  559; 
Extradural  Abscess,  559;  Infective  Sinus  Thrombosis,  559;  Intra- 
cranial Tumors,  560;  Operative  Treatment  of  Epilepsy,  561.  Opera- 
tions on  the  Skull  and  Brain  :  Trephining,  562  ;  Technique  of  Brain- 
operations,  564;  Operation  for  Mastoid  Suppuration,  565. 

XXIII.  Surgery  of  the  Spine 566 

Congenital  Deformities,  566;  Tumors  of  Spine,  567.     Spinal  Curvatures, 

568:  Lateral  Curvature  (Scoliosis),  569;  Antero-posterior  Cui-vature, 
572  ;  Angular  Curvature,  573.  Injuries  of  Spinal  Ligaments  and 
Muscles,  575  :  Traumatic  Hysteria,  577  ;  Malingering,  578.  Concus- 
sion of  Spinal  Cord,  579  ;  Contusion  of  Spinal  Cord,  579;  Wounds  of 
Spinal  Cord,  579;  Compression  of  Spinal  Cord,  580;  Fractures  and 
Dislocations  of  Spine,  580.  Operations  on  Spine :  Treves'  Operation 
for  Vertebral  Caries  (see  p.  479)  ;  Laminectomy,  582. 

XXIV.  Surgery  of  Respiratory  Organs 583 

(i)  Diseases  and  Injuries  of  Nose  and  Antrum:  Foreign  Bodies  in 

Nose,  583  ;  Inflammation  and  Abscess  of  Antrum  of  Highmore  (Max- 
illary Antrum"),  583.  (2)  Diseases  and  Injuries  of  Larynx  and 
Trachea:  CEdema  of  Lar}^nx  (CEdema  of  Glottis),  584;  V^''ounds 
and  Injuries  of  Larynx,  585  ;  Foreign  Bodies  in  Air-passages,  585. 
(3)  Operations  on  Larynx  and  Trachea:  Tracheotomy,  588; 
High  Tracheotomy,  590;  Quick  Laryngotomy,  591;  Intubation  of 
Larynx  (O'Dwyer's  Operation),  592.  (4)  Diseases  and  Injuries 
OF  Chest,  Pleura,  and  Lungs  :  Pleuritic  Eft'usion,  593 ;  Empyema, 
593;  Contusions  and  Wounds  of  Chest,  594;  Paracentesis  Thoracis, 
594 ;  Thoracotomy,  595 ;  Thoracoplasty,  596. 


CONTENTS. 


13 


PAGE 

XXV.  Diseases  and  Injuries  of  the  Digestive  Tract 597 

Diseases  of  Mouth,  Tongue,  and  (Esophagics  :  Hare-lip  and  Cleft  Palate, 

597  ;  Tongue-tie,  601 ;  Ranula,  601  ;  Excision  of  Tongue,  602 ;  Stric- 
ture of  CEsophagus,  603 ;  Foreign  Bodies  in  CEsophagus,  605. 

XXVI.  Diseases  and  Injuries  of  the  Abdomen 606 

Contusion  of  the  Abdominal  Wall,  606  ;    Rupture  of  Stomach  without 

External  Wound,  606;  Rupture  of  Intestine  without  External  Wound, 
607;  Wounds  of  Abdominal  Wall,  610;  Foreign  Bodies  in  Alimentary 
Canal,  611 ;  Cancer  of  Stomach,  61 1 ;  Cicatricial  Stenosis  of  Oritices  of 
Stomach;  612.  Intestinal  Obstrtidion,  613  :  Symptoms  of  Acute  Intes- 
tinal Obstruction,  615;  Diagnosis,  616;  Prognosis,  618;  Treatment, 
619.  Appendicitis,  620.  Peritonitis,  626  :  Plastic  Peritonitis,  626;  Sep- 
tic Peritonitis,  626 ;  Fibrino-plastic  Peritonitis,  627 ;  Suppurative  Perito- 
nitis, 627  ;  Tubercular  Peritonitis,  629.  Operations  upon  the  Abdofnen  : 
Abdominal  Section,  629 ;  Enterorrhaphy,  or  Suture  of  Intestines,  632  ; 
Pylorectomy  (Excision  of  Pylorus),  634;  Gastrostomy,  635;  Gastro- 
enterostomy, 636.  Enterecfomy,  or  Resection  of  Intestine  :  Enterec- 
toniy  with  Circular  Suturing,  636 ;  Intestinal  Anastomosis,  637  ;  Ingui- 
nal Colostomy  (Maydl's  Operation),  639.  Ahdoininal  Hernia  or  Rtip- 
ture,  640  :  Reducible  Hernia,  641  ;  Irreducible  Hernia,  646  ;  Incar- 
cerated or  ^structed  Hernia,  647  ;  Inflamed  Hernia,  647  ;  Strangu- 
lated Hernia,  648  ;  Herniotomy,  651. 

XXVII.  Diseases  and  Injuries  of  the  Rectum  and  Anus 654 

Hemorrhoids,  or  Files,  654  ;  External  Flemorrhoids,  655  ;  Internal  Hem- 
orrhoids, 655.  Prolapse  of  Rectum,  658;  Ulcer  of  Rectum,  659; 
Stricture  of  Rectum,  660;  Cancer  of   Rectum,  661  ;  Foreign  Bodies 

in  Rectum,  662;  Wounds  of  Rectum,  662;  Ischio-rectal  Abscesses, 
662 ;  Fistula  in  Ano,  662  ;  Praritus  of  Anus,  665  ;  Fissure  of  Anus,  665. 

XXyill.  An.^:sthesia  and  An.^:sthetics 666 

General  Anaesthesia,  666;  Administration  of  Chloroform,  668;  Adminis- 
ti-ation  of  Ether,  669;  Anaesthetic  State  from  Ether  or  Chloroform, 
670;  Treatment  of  Comphcations,  671;  Primary  Anaesthesia,  673; 
Local  Anaesthesia,  673 ;  Cocaine  Hydrochlorate,  674. 

XXIX.  Burns  and   Scalds 675 

Scalds  of  Glottis,  676;  Effects  of  Cold,  677;  Chilblain,  or  Pernio,  677. 

XXX.  Diseases  of  the  Skin  and  Xails 678 

Dermatitis   Venenata,    678;    Furuncle,  or  Boil,  679;    Carbuncle,    680; 

Clavus,  or  Corn,  681;  Warts  (see  p,  215);  Onychia,  682. 


14  CONTENTS. 

XXXI.  Diseases  and  Injuries  of  the  Lymphatics 683 

Lymphangitis,  683.      Lymphadenitis,  683 :  Acute  Lymphadenitis,  683. 

Chronic  Adenitis,  684 ;  Lymphangiectasis,  684 ;  Lymphangioma,  684  ; 
Elephantiasis,  684;  Malignant  Lymphoma,  or  Ilodgkin's  Disease  (see 
p.  203). 

XXXII.  Bandages 685 

Spiral  Reversed  Bandage  of  Upper  Extremity,  686 ;  Spiral  Bandage  of 
all  the  Fingers  (Gauntlet),  686;  Spiral  Bandage  of  Palm  or  Dorsum 
of  Hand  (Demi-gauntlet),  686;  Spica  of  Thumb,  687;  Spiral  Re- 
versed Bandage  of  Lower  Extremity,  687;  Bandage  of  Foot  cover- 
ing Heel  (American  Bandage  of  Foot),  687;  Bandage  of  Foot  not 
covering  Heel  (French  Method),  687 ;  Spiral  Bandage  of  Foot  cover- 
ing Heel  (Ribble's  Bandage;  Spica  of  Instep),  688;  Crossed  Bandage 
of  Both  Eyes,  688;  Borsch's  Eye-bandage,  688;  Barton's  Bandage 
(Figure-of-8  of  Jaw),  689;  Gibson's  Bandage,  689;  Crossed  Bandage 
of  Angle  of  Jaw  (ObUque  Bandage  of  Jaw),  689;  Spica  of  Groin 
(Figure-of-8  of  Thigh  and  Pelvis),  690;  Spica  of  Shoulder,  690; 
Velpeau's  Bandage,  690;  Desault's  Apparatus,  691 ;  Recurrent  Band- 
age of  Head,  692 ;  Recurrent  Bandage  of  a  Stump,  692 ;  T-Bandage 
of  Perineum,  692 ;  Handkerchief  Bandages,  692.  Fixed  Dressings  : 
Plaster-of- Paris  Bandage,  692 ;  Silicate-of-Soda  Dressing,  693. 

XXXIII.  Plastic  Surgery 693 

Displacement,  693;  Interpolation,  694;  Retrenchment,  694.  Skin- 
grafting,  694 :  Reverdin's   Method,  694 ;  Thiersch's  Method,  695. 

XXXIV.  Diseases  and  Injuries  of  the  Genito-urinary  Organs  .    .    696 
Haematuria,  696;  Tests  for  Blood,  696;  Bleeding  from  Kidney-substance, 

697  ;  Vesical  Hemorrhage,  including  Hemorrhage  from  Prostate,  698 ; 
Urethral  Hemorrhage,  698;  Frequency  of  Micturition,  699;  Mobile 
Kidney,  700.  Injuries  of  Kidney  :  Laceration  or  Rupture,  702  ;  Per- 
forating Wounds  of  Kidney,  703 ;  Renal  Calculus,  703 ;  Abscess  of 
Kidney,  705;  Pyelitis  and  Pyelonephritis,  706;  Perinephritis,  706; 
Perinephric  Abscesses,  706;  Hydronephrosis,  707;  Pyonephrosis,  or 
Surgical  Kidney,  708  Operations  on  the  Kidney :  Nephrotomy,  709; 
Nephrolithotomy,  709;  Nephrectomy,  710;  Lumbar  Nephrectomy, 
710;  Abdominal  Nephrectomy,  710;  Nephrorrhaphy,  711.  Retention 
of  Urine,  711.  Injztries  of  the  Bladder :  Contusion  of  the  Bladder, 
714;  Rupture  of  Bladder,  715  ;  Atony  of  Bladder,  716 ;  Vesical  Calcu- 
lus, or  Stone  in  Bladder,  717;  Cystitis,  722;  Tumors  of  Bladder,  725. 
Operations  on  Bladder :  Lateral  Lithotomy,  726 ;  Suprapubic  Lithot- 
omy, 728.  Crushing  of  Vesical  Calculi,  730.  Litholapaxy  (Bigelow's 
Operation),  730.     Cystoto??iy,  735.     Growths  in  Female  Bladder,  736. 


CONTENTS.  1 5 

XXXV.  Diseases  and  Injuries  of  the  Urethra,  Penis,  Testicles, 
Prostate,  Spermatic  Cord,  and  Tunica  Vaginalis 736 

Perineal  Bruises,  736 ;  Rupture  of  Urethra,  737 ;  Foreign  Bodies  in 
the  Urethra,  740.  Urethritis,  or  Injlafjunatioii  of  the  Urethra,  741  : 
Simple  Urethritis,  741 ;  Traumatic  Urethritis,  742  ;  Gouty  Urethritis, 
742;  Eczematous  Urethritis,  742;  Tubercular  Urethritis,  743.  Gonor- 
rhoea, 743 :  Subacute  or  Catarrhal  Gonorrhoea,  744 ;  Irritative  or 
Abortive  Gonorrhoea,  745.  Chronic  Urethral  Discharges  :  Chronic 
Urethral  Catarrh,  745  ;  Chronic  Gonorrhoea,  745  ;  Gleet,  745.  Gonor- 
rhcea  in  the  Female,  749.  Stricture  of  Urethra,  750.  Epispadias,  752; 
Hypospadias,  752.  Chancroid,  752.  Phimosis,  754.  Fracture  of 
Penis,  754;  Gangrene  of  Penis,  754;  Cancer  of  Penis,  754;  Amputa- 
tion of  Penis,  755.  Hypertrophy  of  Prostate  Gland,  755 ;  Retained 
Testicle,  757;  Orchitis,  757;  Castration,  758;  Epididymitis,  758. 
Hydrocele,  758:  Congenital  Hydrocele,  759;  Infantile  Hydrocele, 
759;  Encysted  Hydrocele  of  Cord,  759;  Funicular  Hydrocele,  760. 
Haematocele,  760.     Varicocele,  760, 

XXXVI.  Amputations 761 

Methods  of  Amputating :  Circular  Method,  764;  Modified  Circular 
Method,  765;  Elliptical  Method,  765;  Oval  or  Racket  Method,  766; 
Flap  Method^  766.  Special  Amputatiojis  :  Fingers  and  Hand,  767 ; 
Disarticulation  of  a  Metacarpo-phalangeal  Joint,  768;  Amputation  of 
Thumb,  768;  Amputation  at  Wrist-joint,  768;  Amputation  through 
Forearm,  769;  Disarticulation  of  Elbow-joint,  769;  Amputation  of 
Arm,  770;  Disarticulation  at  Shoulder-joint,  770;  Amputation  of  Toes 
and  Foot,  771;  Amputation  at  Tarso-metatarsal  Articulation,  771; 
Amputation  through  Middle  Tarsal  Joint,  773;  Amputation  at  Ankle- 
joint,  773.  Amputations  of  Leg,  774:  Sedillot's  Leg  Amputation,  774; 
Modified  Circular  Amputation  of  Leg,  775 ;  Amputation  of  Leg  by  a 
Long  Postenor  and  a  Short  Anterior  Flap,  775  ;  Amputation  just  below 
Knee,  776;  Disarticulation  of  Knee,  776;  Amputation  through 
Femoral  Condyles,  776;  Amputation  of  Thigh,  777;  Disarticulation 
of  Hip-joint,  777.  Bronchocele,  or  Goitre,  778:  Exophthalmic  or 
Pulsating  Goitre,  780. 

XXXVII.  Asepsis  and  Antisepsis 780 

Surgical  Cleanliness,  780;  Dry  Antiseptic  Method,  781.     Preparations 

for  an  Operation,  781  :  Disinfection  of  Instruments,  782;  Antiseptic 
Preparation-  of  Patient,  782;  Antiseptic  Ligatures,  782;  Antiseptic 
Dressings,  7S3.  Preparation  of  Marine  Sponges,  784;  Cleansing 
Vagina  and  Rectum,  785 ;    Senn's  Decalcified  Bone-chips,  785. 


A  Manual  of  Surgery. 


I.    BACTERIOLOGY. 


Bacte-riology  is  the  science  of  micro-organisms.  Though 
a  science  in  the  youth  of  its  years,  bacteriology  has  not  only 
profoundly  altered,  but  it  has  also  revolutionized,  pathology, 
and  our  views  of  surgery  will  be  incomplete,  misleading, 
and  erroneous  without  its  aid. 

Micro-orggsnisms,  microbes,  or  bacteria  are  minute 
vegetable  cells  of  the  class  fungi,  many  of  them  being  vis- 
ible only  by  means  of  a  highly  powerful  microscope  after 
they  have  been  brightly  stained.  The  contents  of  these  cells 
is  protoplasm  enclosed  by  a  structure  like  cellulose.  The 
protoplasm  can  be  stained  by  aniline  colors,  and  the  cell- 
wall  is  more  readily  detected  after  treating  it  with  water, 
which  causes  it  to  swell.  Many  of  these  organisms  are  col- 
ored, others  are  colorless.  Some  move  (motile  bacteria), 
others  do  not  move ;  among  the  motionless  ones  may  be 
mentioned  the  bacilli  of  anthrax  and  tubercle. 

Definite  knowledge  of  these  minute  bodies  and  of  their 
actions  dates  from  the  study  of  fermentation  by  the  cele- 
brated Frenchman,  Pasteur,  who  in  1857  asserted  that  every 
fermentation  has  invariably  its  own  specific  ferment;  that  this 
ferment  consists  of  living  cells ;  that  these  cells  produce 
fermentation  by  absorbing  the  oxygen  of  the  substance  acted 
upon;  that  putrefaction  is  caused  by  an  organized  ferment; 
2  17 


1 8  A   MANUAL    OF  SURGERY. 

that  all  organized  ferments  are  carried  about  in  the  air ;  and 
that  to  entirely  exclude  air  prevents  putrefaction  or  fermenta- 
tion. These  statements,  which  were  radical  departures  from 
accepted  belief,  inaugurated  a  bitter  controversy,  and  in  that 
controversy  were  born  the  microbic  theory  of  disease,  the 
doctrine  of  preventive  inoculation,  and  antiseptic  surgery. 

The  word  microbe,  which  signifies  a  small  living  being, 
was  introduced  in  1878  by  the  late  Professor  Sedillot  of 
Paris.  At  that  time  the  nature  of  these  bodies  was  in  doubt; 
some  thought  them  animal,  and  called  them  inicrozoaria ; 
others  thought  them  vegetable,  and  called  them  niicropJiyta  ; 
the  designation  "microbe"  does  not  commit  us  to  either  view. 
We  now  know  them  to  be  vegetable,  but  the  term  "microbe" 
has  remained  in  use. 

The  fiingi  connected  with  disease  in  man  are  divided  into 
three  classes  : 

1.  Yeasts,  or  Blastomycetes ; 

2.  Moulds,  or  Hyphomycetes ; 

3.  Bacteria,  or  Schizomycetes. 

Yeasts  are  small  cells  which  multiply  by  gemmation,  these 
cells  often  sticking  together  and  forming  branches,  and  con- 
taining spores  when  nourishment  is  insufficient.  They  are 
thought  to  be  vegetative  forms  of  higher  fjingi  (Green).  The 
chief  importance  of  these  cells  is  that  they  cause  fermenta- 
tions ;  they  never  invade  human  tissues.  Yeasts  may  dwell 
on  mucous  membranes,  and  even  in  the  stomach.  Oidinin 
albicans  is  an  yeast-fungus  whose  growth  upon  the  mucous 
membranes  of  the  mouth,  pharynx,  and  oesophagus  causes 
the  disease  known  as  "  thrush." 

Moulds  consist  of  filaments,  each  filament  being  com- 
posed of  a  single  row  of  cells  arranged  end  to  end,  and  all 
filaments  springing  from  a  germinal  tube  which  grows  from 
a  germinating  spore.  Moulds  are  largely  connected  with 
processes  of  decay.     Some  of  them  can  grow  upon  inflamed 


BACTERIOLOGY.  1 9 

mucous  membrane ;  some  invade  the  epidermis,  producing 
certain  skin  diseases  (favus,  tinea  tonsurans,  tinea  versic- 
olor, etc.). 

Actinomycosis  and  Madura-foot  arise  from  the  lodgment 
and  growth  of  moulds  (Fig.  i). 
Actinomycosis  is  a  disease  seen  in 
cattle,  and  occasionally  in  men,  es- 
pecially in  drovers.  Cattle  become 
infected  through  their  food,  the 
fungus  entering  by  a  hollow  tooth 
or  by  a  breach  in  continuity.    The  .    .  ^.   ,  ^ 

■'  •'  Fig.  I. — Actinomj'ces  (Ziegler). 

lower   jaw  is   usually  the   seat  of 

involvement  (lumpy  jaw).  A  tumor  forms,  which  contains 
sero-pus,  and  after  a  time  ruptures  and  discharges.  The 
matter  contains  nodules  of  fungi.  The  bone  may  undergo 
extensive  destruction.  Other  bones  and  various  organs  can 
be  infected.  Iodide  of  potassium  will  sometimes  bring  about 
a  cure.     Extensive  operations  may  be  demanded. 

Bacteria  chiefly  claim  our  attention.  It  is  important  to 
remember  that  the  term  "  bacteria,"  though  applied  to  the 
class  schizoinycctcs,  has  also  a  more  restricted  application — 
that  is,  to  a  division  of  the  class ;  it  may  either  mean  schizo- 
niycetes  in  general,  or  rod-shaped  schizoinycctcs,  whose  length 
is  not  more  than  twice  their  breadth. 

Some  of  the  scJiizoniycctcs  induce  certain  fermentations ; 
others  are  productive  of  putrefaction,  and  are  called  sapro- 
phytes;  still  others,  known  as  the  pathogenic,  cause  various 
diseases.  They  vary  much  in  shape,  size,  color,  and  arrange- 
ment. One  form  cannot  be  transformed  into  another,  but 
each  maintains  its  own  specific  identity.  Every  organism 
comes  from  a  pre-existing  organism,  this  being  tru£  of  all 
forms,  and  spontaneous  generation  is  impossible. 

Forms  of  Bacteria. — The  three  chief  forms  of  bacteria 
are — 


20 


A   MANUAL    OF  SURGERY. 


1.  The  Coccus — bcriy-sliaped  or  round  bacterium  (Fi<^.  2) ; 

2.  The  Bacillus — rod-shaped  bacterium  (Fig.  3); 

3.  The  Spirilliiin — corkscrew-shaped  bacterium  (Fig.  4). 


/— 


Fig.  2. — Micrococcus. 


Fig.  3. — Bacillus. 


Fig.  4. — Spirillum. 


De  Bary  compares  these  forms,  respectively,  with  the 
biUiard-ball,  the  lead-pencil,  and  the  corkscrew. 

Cocci. — We  only  have  to  do  with  cocci  and  bacilli.  Cocci 
may  be   named   according  to   their  arrangement   with    one 


••• 


<^^-; 
V 


B 


/ 
\ 


Fig.    5. — Forms  of  Bacteria. 


Fig.  6.— Zoogloea  (Ball). 


another,  namely  :  in  pairs  they  are  called  diplococci  (Fig.  5  a); 
in  a  chain  they  are  called  streptococci  (Fig.  5  c) ;  in  a  cluster 
like  a  bunch  of  grapes  they  are  called  staphylococci  (Fig.  5  b)  ; 
and  in  an  irregular  mass,  stuck  together  by  a  thick  sub- 
stance, they  constitute  a  zoogloea  (Fig.  6). 

The   cocci  are  often   named  according  to  their  function, 
as,  for  example,  "  pyogenic,"  or  pus-forming.    The  name  may 


BACTERIOLOGY. 


21 


embody  the  form,  arrangement,  color,  and  function;  for 
instance,  staphylococcus  pyogenes  aureus  signifies  a  round, 
golden-yellow  micro-organism,  which  arranges  itself  with  its 
fellows  into  the  form  of  a  bunch  of  grapes,  and  which  pro- 
duces pus. 

Multiplication  of  Bacteria. — Bacteria  multiply  with  great 
rapidity  when  placed  under  suitable  conditions.  They  can 
multiply  by  fission  or  by  spore-formation.  Some  bacteria 
multiply  by  both  methods.  In  fission,  or  segmentation,  the 
cell  elongates  and  about  its  middle  a  constriction  begins, 
wiiich   deepens    until   the  cell   has   divided   into   two   parts. 


Fig.  7. — Divisions  of  a  Micrococcus  (after  Mace). 


Fig.  8. — Divisions  of  a  Bacillus  (after  Mace). 

each  of  which  soon  grows  as  large  as  its  parent  (Figs.  7,  8). 
All  cocci  and  some  bacilli  multiply  by  this  method.  If 
segmentation  of  a  single  cell  and  the  growth  to  maturity 
of  its  products  require  one  hour  (it  really  takes  place  in  less 
time),  a  single  cell  in  a  single  day  will  have  sixteen  million 
descendants  (Cohn). 

Spores. — A  sp07'e  is  a  germ,  and  corresponds  with  the  seed 
of  a  plant.  Most  of  the  bacilli  multiply  by  spore- formation. 
When  spore-formation  is  about  to  occur  in  a  bacillus,  points 


22 


A    MANUAL    OF  SURGERY. 


Fig.  9. — Sporulation  (after  De  Bary). 


of  cloudiness  appear  in  the  protoplasm,  the  cell  generally 
elongates,  and  in  twenty-four  hours  the  cell  is  found  to  con- 
sist of  a  series  of  segments 
like  a  necklace  of  beads,  each 
segment  containing  a  full- 
grovyn  spore  (Fig.  9).  The 
wall  of  the  cell  now  liquefies, 
the  segments  separate,  the 
spores  are  set  free,  and  each 
spore,  under  favorable  con- 
ditions, becomes  a  bacillus. 
When  the  initial  cloudiness 
appears  in  the  middle  of  the 
cell,  it  is  called  an  "  endo- 
spore ;"  when  it  appears  at 
one  or  both  extremities,  it  is  christened  an  "  endspore  "  or 
"  endspores."  When  multiplication  is  by  a  single  endospore, 
the  bacillus  does  not  elongate. 

Life-conditions  of  Bacteria. — In  order  to  grow  and  to 
multiply,  bacteria  require  suitable  soil  and  the  favoring  influ- 
ences of  heat  and  moisture.  The  soil  demanded  consists  of 
highly-organized  compounds  rather  than  crude  substances, 
and  slight  modifications  in  it  may  prove  fatal  to  some  forms 
of  bacterial  life,  but  highly  advantageous  to  others.  The 
fluids  and  tissues  of  the  individual  may  or  may  not  afford 
favorable  soil  for  the  germs  of  disease,  or,  in  the  same  per- 
son, may  afford  it  at  one  time,  and  not  at  another.  Some 
individuals  seem  to  possess  indestructible  immunity  from, 
and  others  are  especially  prone  to,  certain  contagious  dis- 
eases. Impairment  of  health,  by  altering  some  subde  condi- 
tion of  the  soil,  may  make  a  person  liable  who  previously 
was  exempt.  All  organisms  require  water.  If  dried,  no  form 
will  multiply,  and  many  forms  will  die. 

The  presence  of  oxygen  effects  microbic  growth.     Most 


BACTERIOLOGY.  23 

organisms  thrive  best  when  exposed  to  the  oxygen  of  the 
air,  and  they  are  known  as  "  aerobic."  The  term  "  anaerobic  " 
is  employed  to  designate  organisms  that  can  hve  without 
free  oxygen  ;  they  require  this  gas,  but  are  capable  of  extract- 
ino-  it  from  its  combinations  in  tissues.  An  organism  which 
can  grow  indifferently  where  oxygen  is  plenty  or  where  free 
oxygen  is  absent  is  called  a  "  facultative-aerobic  "  bacterium. 
A  sensitive  organism  which  dies  when  the  amount  of  oxygen 
is  even  slightly  diminished  is  called  an  "  obligate-aerobic  " 
bacterium.  Most  microbic  diseases  in  man  are  due  to 
facultative-aerobic   bacteria. 

Effect  of  Heat  and  Cold. — Most  fungi  grow  best  when 
at  rest ;  agitation  retards  the  growth  of  some  and  kills  others. 
Temperature  is  of  importance  to  bacterial  growth.  Some 
organisms  will  only  grow  within  narrow  temperature  limits, 
while  others  can  sustain  sweeping  alterations,  but  most  grow 
best  between  the  limits  of  from  86°  to  104°  Fahrenheit. 
Freezing  renders  bacteria  motionless  and  incapable  of  multi- 
plication, but  it  does  not  kill  them  :  they  again  become  active 
when  the  temperature  is  raised.  The  absurdity  of  employ- 
ing cold  as  a  germicide  is  evident  when  the  fact  is  known 
that  a  temperature  of  200°  F.  below  zero  is  not  fatal  to  germ- 
life,  its  activities  only  being  rendered  dormant.  High  tem- 
peratures are  fatal  to  bacteria;  moist  heat  is  more  destructive 
than  dry  heat,  and  adult  cells  are  more  vulnerable  than 
spores.  A  temperature  less  than  212°  F.  will  kill  many 
organisms,  and  boiling  will  kill  every  organism  that  does 
not  form  spores.  Some  spores  are  not  destroyed  after  pro- 
longed boiling,  and  some  will  withstand  a  temperature  of 
120°  C.  As  a  practical  fact,  however,  boiling  water  kills,  in 
a  few  minutes,  all  cocci,  most  bacilli,  and  many  spores; 
though  the  spores  of  anthrax,  tetanus,  and  malignant  oedema 
are  not  with  certainty  destroyed.  Sunlight  antagonizes  some 
forms  of  bacterial  growth. 


24  A   MANUAL    OF  SUKGEKY. 

Chemical  Germicides. — Many  chemical  agents  will  kill 
bacteria,  the  most  certain  of  them  all  being  corrosive  sub- 
limate. Koch  showed  that  corrosive  sublimate  is  an  efficient 
germicide  when  present  in  the  proportion  of  only  I  part  to 
50,000.  It  is  used  in  surgery  in  strengths  of  i  part  of  the 
salt  to  1000,  2000,  3000  or  more  parts  of  water.  Because 
of  the  fact  that  contact  with  albumin  precipitates  from  a 
solution  of  corrosive  sublimate  an  insoluble  albuminate  of 
mercury,  in  surgical  operations  by  the  wet  method  consider- 
able quantities  must  be  used ;  or  the  mercury  is  combined 
with  tartaric  acid  in  the  proportion  of  i  to  5,  which  com- 
bination prevents  the  insoluble  albuminate  from  being  formed. 

Carbolic  acid  is  a  valuable  germicide  in  the  strength  of 
from  I  :  40  to  I  :  20.  It  is  certainly  fatal  to  pus-germs. 
Unfortunately,  this  acid  attacks  the  hands  of  the  surgeon ; 
consequently  in  the  United  States  it  is  chiefly  employed  as 
an  antiseptic  medium  in  v/hich  to  place  the  operating-instru- 
ments. Iodoform  is  largely  used;  it  is  not  truly  a  germi- 
cide, as  bacteria  will  grow  upon  it,  but  it  hinders  the  devel- 
opment of  bacteria  and  directly  antagonizes  the  toxic  prod- 
ucts of  germ-life.  Kreolin,  which  is  a  preparation  made 
from  coal,  is  a  germicide  without  irritant  or  toxic  effects. 
It  is  less  powerful  than  carbolic  acid,  and  is  used  in  an 
emulsion  of  a  strength  of  from  i  to  5  per  cent.  Peroxide 
of  hydrogen  is  a  most  admirable  agent  for  the  destruction 
of  pus  cocci.  It  comes  in  a  15-volume  solution,  which  is 
diluted  one-half  or  two-thirds.  It  probably  destroys  the 
albuminous  element  upon  which  the  bacteria  live.  The  per- 
oxide of  hydrogen  is  not  fatal  to  tetanus  bacilli. 

Distribution. — Microbes  are  very  widely  distributed  in 
nature.  They  are  found  in  all  water  except  that  which 
comes  from  very  deep  springs  ;  in  all  soil  to  a  depth  of 
3  feet ;  and  in  air,  except  that  of  the  desert,  on  the  open  sea, 
and  on  lofty  mountains. 


BACTERIOLOGY.  25 

Microbes  may  be  useful.  Some  of  them  are  scaveno-ers 
and  clean  the  surface  of  the  earth  of  its  dead  by  the  process 
known  as  "  putrefaction,"  in  which  complex  organic  matter 
is  reduced  to  harmless  gases  and  to  a  mineral  condition,  the 
gases  being  taken  up  from  the  air  by  vegetables,  and  the 
mineral  matter  dissolving  in  rain-water  and  passing  again 
into  the  soil  from  which  it  came,  there  again  to  be  food  for 
plants  which  become  food  for  animals.  Other  organisms 
purify  rivers ;  others  again  cause  bread  to  rise ;  still  others 
give  rise  to  fermentation  in  liquors.  Microbes  may  be  harm- 
ful. They  may  poison  rivers  and  soils  ;  they  may  be  parasites 
on  vegetable  life ;  they  cause  disease  of  the  grape  and  wine ; 
they  mould  bread ;  they  poison  sausage  and  canned  foods; 
and  they  produce  many  diseases  among  men  and  the  lower 
animals. 

With  so  universal  a  distribution  of  these  fungi,  man  must 
constantly  take  them  into  his  organism.  They  are  upon  the 
surface  of  his  body,  he  inhales  them  with  every  breath,  and 
he  swallows  them  with  his  food  and  drink.  Most  of  them, 
fortunately,  are  entirely  harmless ;  others  cannot  act  on  the 
living  tissues  ;  but  some  are  virulent,  and  these  are  generally 
destroyed  by  the  cells  of  the  human  body.  The  alimentary 
canal  always  contains  bacteria  of  putrefaction,  which  act 
only  upon  the  dead  food,  and  not  upon  the  living  body; 
but  when  a  man  dies  these  ors^anisms  at  once  attack  the 
tissues,  and  post-mortem  putrefaction  begins  in  the  abdomen. 

Koch's  Circuit. — To  prove  that  a  microbe  is  the  cause 
of  a  disease  it  must  fulfil  Koch's  circuit.  It  must  always  be 
found  associated  with  the  disease  ;  it  must  be  capable  of 
forming  pure  cultures  outside  the  body  ;  these  cultures  must 
be  capable  of  reproducing  the  disease ;  and  the  microbe 
must  again  be  found  associated  with   the  morbid  process. 

When  disease-producing  organisms  enter  the  body,  they 
are    usually    rapidly    destroyed ;    they    cannot    dwell    there 


26  A    MANUAL    OF  SURGERY. 

long  without  inducing  disease,  but  spores  can  lie  dormant 
in  the  system  for  years,  only  waking  into  activity  when 
they  come  in  contact  with  some  damaged,  weakened,  or  dis- 
eased part — a  so-called  point  of  least  resistance  (a  locus 
minoris  rcsistcntice) — which  affords  a  nest  for  them  to  develop 
and  to  multiply,  the  cellular  activities  of  the  weakened  part 
being  unable  to  cope  with  the  organism.  Even  large  doses 
of  pathogenic  organisms  may  induce  no  trouble  in  a  healthy 
man ;  but  let  them  reach  a  damaged  spot,  and  mischief  is 
apt  to  arise.  Kocher  established  subcutaneous  bone-injuries 
in  dogs,  and  these  injuries  pursued  a  healthy  course  until 
the  animal  was  fed  upon  putrid  meat,  whereupon  suppura- 
tion took  place.  This  experiment  proves  that  an  organism 
can  reach  a  damaged  area  by  means  of  the  blood,  and  it 
enables  us  to  understand  how  a  knee-joint  can  suppurate 
when  we  merely  break  up  adhesions,  and  how  osteo-myelitis 
can  follow  trauma  when  the  skin  is  intact. 

Toxalbumins  and  Toxines. — The  action  of  pathogenic 
bacteria  upon  the  tissues  is  of  great  importance.  In  the 
first  place,  they  abstract  from  the  blood,  the  lymph,  and  the 
cells  certain  elements  necessary  to  the  body — as  water,  oxy- 
gen, albumins,  carbohydrates,  etc. — and  bring  about  body- 
wasting  and  exhaustion  from  want  of  food.  In  the  second 
place,  bacteria  produce  a  series  of  compounds,  some  harm- 
less and  others  highly  poisonous.  These  organisms  contain 
and  secrete  ferments  like  pepsin  or  trypsin,  and  as  albumoses 
are  formed  in  the  alimentary  canal  by  the  digestive  ferments, 
which  split  up  proteids,  sugars,  and  starches,  we  have  microbic 
albumoses.  Just  as  the  albumoses  formed  in  digestion  are 
poisonous  when  injected,  so  are  the  albumoses  of  microbic 
action,  and  they  are  called  "toxalbumins."  These  albu- 
moses  often  operate  as  virulent  poisons  to  the  body-cells. 

Another  assemblage  of  compounds  formed  by  the  microbic 
destruction  of  tissue  is  designated  the  group  of  "  toxines." 


BA  CTERIOL  OGY.  2/ 

These  toxines  are  poisonous  alkaloids  which  are  readily- 
diffusible  and,  many  of  them,  very  virulent.  It  is  probable 
that  every  pathogenic  organism  has  its  own  special  toxine 
which  produces  its  own  characteristic  effects.  The  absorp- 
tion of  toxines  may  be  very  rapid ;  for  instance,  the  toxines 
of  cholera  may  kill  a  man  before  the  bacillus  has  migrated 
from  the  intestine. 

Ptomaines. — By  many  writers  the  term  "  ptomaine  "  is 
used  to  designate  these  toxines,  but  in  reality  a  ptomaine 
is  a  form  of  toxine  that  is  due  to  the  action  of  saprophytic 
bacteria.  A  ptomaine  is  a  putrefactive  alkaloid,  and  a  toxine 
is  any  poisonous  alkaloid  of  microbic  origin.  Among  these 
poisonous  alkaloids  may  be  mentioned  tetanine,  typhotoxine, 
sepsine,  putrescine,  muscarine,  and  spasmotoxine. 

Leucomaines  must  not  be  confounded  with  the  above- 
mentioned  bodies.  Leucomaines  are  alkaloid  substances 
existing  newmally  in  the  tissues,  and  arising  from  physio- 
logical fermentations  or  retrograde  chemical  changes.  They 
are  natural  body-constituents,  in  contrast  to  toxines,  which 
are  morbid.  Leucomaines  are  found  in  expired  air,  saliva, 
urine,  various  tissues,  and  the  venom  of  serpents.  If  not 
excreted,  these  bodies  can  induce  illness,  and  when  injected 
can  act  as  poisons.  Ordinary  colds  and  some  fevers  result 
from  leucomaines  ;  they  play  a  great  part  in  uraemia,  and 
when  excretion  is  deficient  and  leucomaines  are  retained 
they  make  the  system  a  hospitable  host  for  pathogenic 
bacteria.  Among  leucomaines  may  be  mentioned  adenine, 
hypoxanthine,  and  xanthine,  allied  to  uric  acid,  and  other 
substances  allied  to  creatine  and  creatinine. 

Antitoxines. — Another  group  of  substances  arising  from 
microbic  action  are  known  as  "  antitoxines."  It  is  a  well- 
recognized  fact  in  fermentation  that  after  a  time  the  process 
ceases,  and  the  addition  of  more  ferment  is  void  of  result. 
The    same   is  true   of  specific    maladies ;    thus,  if  a  person 


28 


A   MANUAL    OF  SURGERY. 


recovers,  the  organisms  disappear,  and  the  injection  of  more 
of  them  produces  no  result;  in  other  words,  immunity 
exists  toward  the  disease.  This  immunity  was  long  believed 
to  arise  from  the  exhaustion  of  some  unknown  constituent 
of  tissue  necessary  to  the  life  of  the  bacteria.  It  is  now 
believed  to  be  due  partly  to  the  capacity  of  the  amceboid 
cells  to  destroy  germs,  and  partly  to  the  production  of  anti- 
toxines  which,  when  they  have  developed  in  sufficient  amount, 
destroy  the  cells  that  made  them.  In  other  words,  the  fact 
seems  to  be  established  that  bacteria  not  only  produce 
poisons,  but  also  the  antidotes  for  them. 

Phag-ocytes. — The  tendency  of  the  white  blood-cells  and 
of  the  fixed  tissue-cells  to  destroy  organisms  is  undoubted. 
This  process  of  destruction  is  known  as  "  phagocytosis,"  and 
the  destroying  cells  are  called  "  phagocytes."  These  cells 
try  to  eat  up  and  destroy  the  germs.     A  battle-royal  occurs, 


Fig.  io. — Phagocytosis  :  a,  successful,  b,  unsuccessful  (Senn). 

the  microbe  fighting  the  body-cells  with  most  active  ferments, 
the  body-cells  endeavoring  to  devour  and  engulf  the  bacteria 
(Fig.  lo).  In  some  cases  the  bacteria  win  absolutely  and 
the  patient  dies.  In  other  cases  they  win  for  a  time  and 
overwhelm  the  organism,  but  presently  the  body-cells,  whose 


BA  CTERIOL  OGY.  2g 

movements  were  inhibited  by  poison,  regain  their  activity 
and  successfully  recur  to  the  attack.  After  the  attack  is 
over  the  body-cells  have  been  educated  to  withstand  this 
poison,  and  their  descendants  retain  this  capacity ;  the  weak 
cells  were  killed,  the  fittest  survived,  and  the  descendant 
cells  of  the  survivors  are  born  insusceptible.  This  is  inwiu- 
iiity,  and  lasts  for  a  varying  period.  Some  persons  seem, 
from  birth,  immune  to  certain  maladies.  The  theory  of 
phagocytosis  immunity  assumes  an  educated  white  corpuscle 
and  body-cell.  This  view  originated  with  Sternberg,  but  it 
is  usually  accredited  to  Metschnikoff 

Protective  and  Preventive  Inoculations. — Our  know- 
ledge of  protective  inoculations  for  contagious  diseases  dates 
from  Jenner's  discovery  in  1768.  Preventive  inoculations 
with  attenuated  virus  are  due  to  the  experiments  of  Pasteur. 
This  observer  discovered  the  cause  of  chicken-cholera,  and 
he  cultivated  the  micro-organism  of  this  disease  outside  the 
body.  He  found  that  by  keeping  his  cultures  some  time 
they  became  attenuated  in  virulence,  and  that  these  attenu- 
ated cultures,  inoculated  in  fowls,  caused  a  mild  attack  of 
the  disease,  which  attack  was  protective,  and  rendered  the 
fowl  immune  to  the  most  virulent  cultures.  Cultures  can  be 
attenuated  by  keeping  them  for  some  time,  by  exposing 
them  for  a  short  period  to  a  temperature  just  below  that 
necessary  to  kill  the  organisms,  and  by  treating  them  with 
certain  antiseptics.  It  has  further  been  shown  that  injection 
of  the  blood-serum  of  an  animal  rendered  immune  by  inocu- 
lation is  capable  of  making  a  susceptible  animal  also  immune. 

A  most  important  fact  is  that  animals  may  be  rendered 
immune  by  inoculating  them  with  filtered  cultures,  the  fil- 
trate containing  microbic  products,  but  not  living  microbes. 
By  this  method  animals  can  be  rendered  immune  to  tetanus 
and  diphtheria.  Pasteur's  protective  inoculations  against 
hydrophobia    owe    their  power  to   microbic    products,   and 


30  A   MANUAL    OF  SURGERY. 

Koch's  lymph  contains  them  as  its  active  ingredients.  The 
chief  feature  in  acquired  immunity  is  the  presence  in  the 
blood  of  elements  which  can  neutralize  the  toxic  products 
of  bacteria.  These  elements  are  called  "  antitoxines,"  or 
defensive  proteids.  The  present  knowledge  of  them  arose 
from  the  discovery  of  Nuttall  and  Buchncr  that  fresh  blood- 
serum  is  germicidal,  the  power  varying  for  different  bacteria 
and  being  limited,  for  a  fixed  amount  of  serum  is  capable  of 
destroying  a  small  dose  of  bacteria  only.  It  has  been  shown 
that  in  tetanus  injections  of  the  serum  of  an  immune  ani- 
mal can  cure  the  disease.  The  above  facts  are  of  immense 
importance,  for  on  these  lines  will  be  solved  the  prevention 
and  treatment  of  microbic  maladies. 

Antag-onistic  Microbes. — Another  observation  of  import- 
ance is  that  certain  microbes  are  antagonistic  to  one  another. 
The  streptococcus  of  erysipelas  attacks  the  organism  of 
anthrax.  We  should  note  also  that  the  growth  of  some 
microbes  affects  the  soil  favorably  or  otherwise  for  the 
growth  of  others,  and  the  same  may  be  true  in  the  body. 

Mixed  Infection. — A  fact  of  practical  importance  to  the 
surgeon  is  that  an  area  infected  by  one  form  of  pathogenic 
organism  may  be  invaded  by  another  form.  This  is  known 
as  a  mixed  infection,  and  consists  of  a  primary  infection 
with  one  organism,  and  a  secondary  infection  with  another. 
Koch  found  both  bacilli  and  micrococci  in  the  same  lesion 
of  tubercle.  A  soil  filled  with  pneumococci  is  favorable  to 
the  growth  of  pus  cocci  and  tubercle  bacilli.  Tuberculous 
and  syphilitic  lesions  may  be  attacked  by  erysipelas.  Chancre 
and  chancroid  can  exist  together.  A  syphilitic  ulcer  is  a 
good  culture  for  tubercle  bacilli  (Schnitzler).  Suppuration 
in  erysipelas  or  tuberculosis  means  a  secondary  infection 
with  pus  cocci. 

Placental  Transmission. — The  direct  transmission  of  bac- 
teria from  parents  to  foetus  is  a  problem  still  in  course  of 


BACTERIOLOGY-. 


31 


solution.  Certain  it  is  that  some  diseases  (as  syphilis)  are 
due  to  the  direct  carrying  of  the  microbes  by  sperm-cell  to 
germ-cell,  or  to  the  transmission  of  the  micro-organism 
through  the  septum  of  separation  between  the  circulations  of 
the  mother  and  child.  In  many  other  diseases  the  microbe 
is  not  directly  transmitted  (as  in  phthisis),  but  a  patient  born 
with  weakened  tissue-cells  is  prone  to  fall  a  prey  to  the  latter 
malady. 

Special  Surgical  Microbes. — P21S  microbes,  or  pyogenic 
microbes^  include  the  following  forms : 

I.  Staphylococcus  pyogenes  aureus  (Fig.  11),  which  is  the 
commonest  form,  is  killed  by  a  few  minutes'  boiling,  by  cor- 
rosive sublimate,  or  by  carbolic  acid.  These  microbes  are 
very  widely  distributed  in  the   soil,  air,  and  water,  in   the 


Fig.  II. — Staphylococcus  Pyogenes  Aureus 
in  Pus  (X  1000)  (Frankel  and  Pfeiffer;. 


Fig.  12. — Streptococcus  Pyogenes  m 
Pus  (X  1000)  (Frankel  and  Pfeiffer). 


superficial  layers  of  the  skin,  especially  the  axillae  and  the 
region  of  the  perineum,  and  are  found  in  the  mouth,  phar- 
ynx, alimentary  canal,  and  under  the  nails. 

2.  Staphylococcus  pyogenes  albus. 

3.  StaphylococcJis  pyogenics  citretis. 

4.  Streptococcus  pyogenes,  which  is  found  normally  in  the 
nose,  saliva,  vagina,  and  urethra  (Fig.  12). 

5.  Bacillus  pyocyaneus,  which  exists  in  blue  pus. 


32 


A   MANUAL    OF  SURGERY. 


These  pyogenic  cocci  subsist  in  all  acute  abscesses.  The 
staphylococci  exist  in  circumscribed  suppurations,  as  in  boils 
and  carbuncles;  the  streptococci,  in  spreading  inflammations, 
as  in  erysipelas  and  cellulitis. 

Can  suppuration  exist  without  cocci  ?  It  can,  but  prac- 
tically does  not.  The  injection  of  irritants  may  form  a  thin 
fluid  resembling  pus,  but  containing  no  bacteria.  The  prod- 
ucts of  bacterial  action  when  injected  will  form  pus.  But 
practically  in  surgery  to  exclude  cocci  is  to  prevent  the 
formation  of  pus.  Cocci  form  pus  by  liquefying  inflam- 
matory products  or  tissues.  Cold  abscesses  are  due  to 
tubercle  bacilli,  and  they  do  not  contain  pus  cocci  unless 
mixed  infection  exists. 

Other  Surg-ical  Microbes. — Streptococcus  erysipclatis  re- 
sembles   streptococcus  pyogenes,   and    they   are    thought    by 

many  to  be  identical.  Their 
difference  in  action  is  consid- 
ered to  be  due  to  difference  in 
virulence  induced  by  external 
conditions  and  the  state  of  the 
tissues.  The  gonococcus,  or 
Neisser's  bacillus,  is  a  diplo- 
coccus,  and  is  the  specific  or- 
ganism of  gonorrhoea  (PI.  i, 
Fig.  2).  The  tetanus  bacillus, 
or  the  bacillus  of  Nicolaier, 
exists  chiefly  in  the  soil  of  gar- 
dens, in  manures  about  stables, 
and  in  masonry  (PI.  i,  Fig.  i). 
The  bacillus  tuberculosis,  or 
Koch's  bacillus,  the  cause  of 
all  tuberculous  processes,  exists  particularly  in  air  infected 
by  the  dried  sputum  of  tuberculous  subjects.  This  infected 
air  is  the  chief  means  of  its  transmission.      It  is  found  also 


Fig.  13. — Anthrax  Bacilli  in   Blood 
(Vierordtj. 


IN  FLA  MM  A  TION.  3  3 

in  the  milk  of  tuberculous  cows.  Such  milk  can  spread 
the  disease  (PI.  i,  Fig.  3).  The  bacillus  ccdcmatis  nialigiii 
gives  rise  to  malignant  oedema.  The  bacillus  of  syphilis,  or 
Lustgarten's  bacillus,  is  not  definitely  determined  to  be  the 
cause  of  syphilis.  The  bacillus  mallei  is  the  bacillus  of 
glanders.  The  bacillus  anthracis  is  the  bacillus  of  anthrax, 
splenic  fever,  wool-sorter's  disease,  or  malignant  pustule 
(Fig.  13).  The  j'ay  fungus  causes  actinomycosis.  Strepto- 
cocci are  found  in  noma.  No  specific  organism  has  been 
isolated  for  traumatic  spreading  gangrene  or  hospital 
gangrene;  'only  pus  cocci  have  been  found.  The  bac- 
terium coli  communis  is  the  supposed  cause  of  peritonitis 
{q.  v.). 

11.    INFLAMMATION. 

Definition. — Inflammation  is  a  nutritive  disturbance  aris- 
ing from  tii^sue -damage,  and  is  not  an  increase  of  nutrition. 
It  is  defined  bv  Burden-Sanderson  as  "  the  succession  of 
changes  which  occur  in  a  living  tissue  when  it  is  injured, 
provided  that  the  injury  is  not  of  such  a  degree  as  at  once 
to  destroy  its  structure  and  vitality."  The  changes  alluded 
to  in  this  definition  comprise — (i)  changes  in  the  vessels  and 
the  circulation ;  (2)  exudation  of  fluids  and  solids  from  the 
vessels ;  and  (3)  changes  in  the  perivascular  tissues. 

Vascular  and  Circulatory  Chang-es  are  essential  to  in- 
flammation in  both  vascular  and  non-vascular  tissues.  In 
the  former  they  occur  in  the  tissues ;  in  the  latter  (cornea 
and  cartilage)  they  are  manifest  in  neighboring  tissues  from 
which  the  non- vascular  area  derives  its  nutritive  material. 

Active  Hyperaemia. — When  an  irritant  is  applied  to  tis- 
sue, there  may  be  a  momentary  arterial  contraction  due  to 
irritation  of  the  nerves,  but  this  contraction  is  transitory, 
and  is  not  an  inflammatory  phenomenon.  The  first  vascu- 
lar phenomenon  is  dilatation  of  all  the  vessels — capillaries, 
3 


34 


A   MANUAL    OF  SURGERY. 


venules,  and  arterioles — appearing  first,  and  being  most  pro- 
nounced, in  the  small  arteries.  As  a  result  of  this  dilatation 
there  is  increased  rapidity  of  circulation  and  increased  deter- 
mination of  blood  to  the  part.  This  condition  of  increased 
circulatory  activity  is  known  as  "active  hyperaemia"  (Fig.  i  5). 
Retardation. — During  active  hyperaemia  the  capillaries 
are  crowded  with  corpuscles  and  the  blood  in  the  veins  is 
of  a  much  brighter  red  than  in  health.  The  red  blood-cells 
are  swept  along  the  centre  of  the  current  (in  the  axial 
stream),  the  white  blood-cells  float  lazily  along  near  the 
vessel-wall.  After  a  variable  time  the  blood-current  begins 
to  slow  down  until  it  becomes  more  tardy  than  in  health. 


Fig.  14. — Normal  Vessels  and  Blood-stream  :   a,  artery  ;   d,  vein  ;    c,  capillary  (Landerer). 

This  is  known  as  "  retardation  of  the  circulation."     Retarda- 
tion  is   first  noted  in  the   capillaries,  next  in   the  venules, 


JNFLAMMA  TION. 


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36  A   MANUAL    OF  SURGERY. 

and  last  in  the  arterioles ;  but  arterial  pulsation  continues. 
The  white  cells  show  a  strong  tendency  to  adhere  to  the 
vein-walls,  and,  as  a  result,  accumulate  against  the  inside  of, 
and  stick  to,  these  walls  and  to  one  another  until  the  veins 
are  entirely  lined  with  layers  of  leucocytes.  In  the  capillaries 
some  leucocytes  gather,  but  not  many.  In  the  arteries  they 
try  to  adhere  during  cardiac  dilatation,  but  are  swept  away 
by  the  force  of  the  heart's  contraction. 

Oscillation  and  Stagnation. — By  this  accumulation  of 
leucocytes  the  blood-stream  is  progressively  narrowed  and 
the  axial  current  is  impeded.  The  red  blood-cells  begin  to 
stick  to  one  another,  forming  aggregations  like  rouleaux 
of  coin,  which  increase  the  difficulty  the  axial  current  has 
to  contend  with,  until  progressive  movement  ceases  and  the 
contents  of  the  vessels  sway  to  and  fro  with  the  pulse.  This 
is  the  stage  of  oscillation.  In  a  short  time  oscillation  ceases 
and  the  vessels  are  filled  with  blood  which  does  not  move. 
This  is  known  as  "  stasis  "  or  "  stagnation."  If  stasis  per- 
sists, we  get  coagulation  or  thrombosis.  We  can  then  sum 
up  the  vascular  changes  of  inflammation  by  stating  that  they 
consist  in  a  dilatation  of  the  vessel-w^alls,  in  a  primary  accele- 
ration, a  secondary  retardation,  and  a  subsequent  stagnation 
of  the  blood-current  with  adhesion  of  leucocytes  to  the 
walls  of  veins  and  capillaries,  and  in  the  aggregation  into 
masses  of  the  red  blood-cells  (Fig.  i6). 

Exudation  of  Fluids. — It  is  to  be  remembered  that  in 
ordinary  nutrition  serum  and  white  cells  pass  into  the  tis- 
sues through  the  walls  of  vein  and  capillary.  In  inflam- 
mation the  same  thing  happens,  but  the  exudation  is  vastly 
greater  in  amount  and  is  different  in  composition.  In  any 
slight  inflammation,  and  in  the  early  stages  of  any  inflam- 
mation, there  is  an  increase  in  the  serous  exudate,  and  we 
speak  of  the  condition  as  "  serous  inflammation."  This  fluid 
is  really  not  serum,  but  is  liquor  sanguinis.     We  find  serum 


IN  FLA  MMA  TION.  37 

in  passiv^e  congestion,  not  in  active  hyperaemia.  It  contains 
very  few  white  cells.  If  the  inflammation  goes  no  further, 
the  exuded  serum  is  drunk  up  by  the  lymphatics.  A  blister 
is  an  example  of  serous  inflammation.  If  the  inflammation 
continues  to  intensify,  the  exudation  is  altered  in  charac- 
ter— it  becomes  thicker,  turbid,  and  very  coagulable.  It 
contains  white  cells  and  fibrin  elements,  and  coagulates  in 
the  tissues.  This  fluid  is  known  as  "lymph"  or  plastic 
exudation,  and  when  it  is  present  we  speak  of  the  condi- 
tion as  "  plastic  inflammation."  The  lymphatics  endeavor  to 
absorb  the  fluid,  but  it  occludes  them  by  coagulation,  and 
the  area  they  drain  becomes  swollen,  hard,  and  "  branny." 
This  lymph  can  be  seen  in  the  anterior  chamber  of  the  eye 
in  cases  of  plastic  iritis. 

Diapedesis  or  Migration. — Even  early  in  an  inflammation 
some  few  white  corpuscles  pass  through  the  vessel-walls ; 
but  Vv^hen  the  inflammation  is  well  established  large  numbers 
pass,  and  when  it  is  severe,  vast  hordes.  This  process  is 
known  as  *' diapedesis "  or  "migration."  The  leucocytes 
throw  out  protoplasmic  arms,  insert  themselves  between  the 
cells  of  the  walls,  and  pull  themselves  through  by  their 
amoeboid  movements.  They  do  not  pass  through  existing 
open  doors,  but  form  openings  which  close  after  them. 
This  is  readily  accomplished,  because  the  vessel-wall  is  itself 
damaged,  weakened,  and  convoluted.  This  escape  of  leuco- 
cytes takes  place  chiefly  from  the  venules,  though  some 
migrate  through  the  capillaries  and  arterioles   (Fig.  17). 

In  very  acute  inflammation  the  vessel-walls  are  so  dam- 
aged that  red  corpuscles  also  escape,  making  the  tissue 
appear  as  if  infiltrated  with  blood.  The  white  corpuscles 
greatly  increase  in  number  in  the  blood  of  a  person  who 
has  an  acute  inflammation,  and  the  blood-making  organs, 
such  as  the  spleen  and  h^mphatic  glands,  are  often  enlarged. 
The  blood-plaques  or  third  corpuscles  are  found  to  be  pres- 


38 


A   MANUAL    OF  SURGERY. 


ent  in  increased  numbers.  These  blood-plaques  are  not  seen 
in  moving  blood,  but  are  found  in  blood-clot,  their  usual 
proportion  to  red  cells  being  as  i  to  20,  and  they  are  espe- 
cially numerous  at  the  height  of  fever  processes  and  during 
convalescence  from  an  extensive  abscess. 

Changes    in    the    Perivascular   Tissues. — The    exuded 
liquor  sanguinis  coagulates,  and  as  a  result  of  the   exuda- 


10.30  p.  M. 


10.40 


11.15 


11.40 


12.20 


Fig.  17. — Stages  of  the  Migration  of  a   Single  White  Blood-corpuscle  through   the   wall 
of  a  vein  in  two  hours  and  ten  minutes  (mesentery  of  the  frog)  (Caton"). 

tion  of  elements  of  the  blood  the  tissues  are  softened,  sep- 
arated, and  overfed.  The  abundance  of  food  causes  them 
to  multiply,  and  this  is  known  as  "  cell-proliferation."  To 
the  proliferating  cells  of  the  perivascular  tissues  are  added 
the  migrated  leucocytes,  and  we  soon  get  a  mass  of  small 
round  or  oval  cells,  held  together  by  gelatinous  intercellular 
material,  called  "  embryonic  tissue,"  inflammatory  or  organ- 
ized new  formation,  or  plastic  infiltration.  The  tissues  have 
reverted  to  a  condition  identical  with  those  of  the  embryo 
as  the  first  step  in  repair.  The  above  complicated  processes 
are   not  accidents   nor  haphazard   freaks,  but  are   Nature's 


INF  LA  MMA  TION.  3  9 

efforts  to  bring  about  a  cure.  The  acceleration  of  the  circu- 
lation is  an  attempt  to  wash  away  offending  material ;  when 
this  fails,  congestion  is  relieved  by  exudation  and  migration, 
the  blood  becoming  albuminous  and  more  corpuscular  in 
order  that  foreign  bodies  may  be  encapsuled  or  extruded, 
so  that  damaged  parts  may  be  amply  repaired  and  that  vital 
structures  may  be  protected  and  shielded. 

Dilatation  is  due  to  the  direct  effect  of  the  injury  upon 
the  muscle  or  its  nerve-elements,  and  not  to  reflex  action, 
as  it  occurs  even  when  the  nerves  have  all  been  divided. 
Retardation  and  stasis  are  due  primarily  to  an  altered  con- 
dition of  the  vessel-wall,  which  caused  resistance  to  the 
passage  of  the  blood-stream  and  adhesion  of  the  cells  to  the 
vessel.  It  may  be  increased  secondarily  by  the  pressure  of 
an  enormous  exudate,  producing  tension.  This  tension  may 
be  so  great  as  to  produce  sloughing. 

Classafication  of  Inflammations. — The  various  forms  of 
inflammations  are — (l)  Simple  or  conunon^  that  which  is  due 
to  any  ordinary  traumatic,  chemical,  or  thermal  cause,  and 
not  to  bacteria,  such  as  traumatic  periostitis  or  sun  dermatitis. 
It  does  not  tend  particularly  to  spread ;  (2)  infective  or 
specific,  that  which  is  due  to  micro-organisms,  as  erysipelas. 
An  unsuccessful  attempt  has  been  made  to  charge  all 
inflammations  to  bacteria.  It  is  true  that  they  can  generally 
be  found  in  inflammatory  areas,  but  that  they  alone  can  be 
causative  is  accepted  by  but  few.  Infective  inflammations 
tend  to  spread  widely ;  (3)  traumatic,  which  is  due  to  a  blow 
or  an  injury;  (4)  idiopat/iic,  \x\\\ch  is  without  an  ascertain- 
able cause.  There  is  certain!}'  a  cause,  however,  even  if  it 
cannot  be  pointed  out ;  (5)  acute,  which  is  rapid  in  course 
and  violent  in  action ;  (6)  chronic,  which  follows  a  pro- 
longed course  ;  (7)  subacute,  which  is  intermediate  in  violence 
and  duration  between  acute  and  chronic ;  (8)  sthenic,  charac- 
terized by  high  action.     Occurs  in  strong  young  subjects  ; 


40  A    MANUAL    OF  SURGER  V. 

(9)  astJicnic  or  adynamic,  occurring  in  the  old,  the  debili- 
tated, and  the  broken-down.  It  is  unable  to  reach  a  suffi- 
cient degree  to  limit  itself;  (10)  parciiclLyniatous,  affecting  the 
"parenchyma,"  or  active  cells  of  an  organ;  (11)  interstitial, 
affecting  the  connective-tissue  stroma;  ( 1 2)  5^r<9//5,  character- 
ized by  profuse  serous  exudation,  as  in  pleuritis,  or  by  marked 
inflammatory  oedema;  (13)  plastic,  adJicsivc,  or  fibrinous, 
characterized  by  an  exudation  which  glues  together  adjacent 
surfaces,  as  in  peritonitis;  (14)  purtdcjit,  phlegmonous,  or 
suppurative,  when  the  pus  cocci  are  present  and  multiply; 

(15)  hemorrhagic,  when  the  exudate  contains  many  red  blood- 
cells,  as   in   strangulated    hernia    and   in   black    small-pox ; 

(16)  croupous,  when  an  inflammation  produces  upon  the 
surface  of  a  membrane  a  fibrinous  exudate  which  cannot  be 
organized  (aplastic  lymph),  and  which  is  due  to  the  action 
of  micro-organisms,  usually  on  mucous  membrane;  (17) 
diphtheritic,  which  differs  from  croupous  in  the  fact  that  the 
false  membrane  is  in  the  tissue  rather  than  upon  it;  (18) 
gangrenous,  or  death  of  the  part,  which  occurs  from  tension 
of  the  exudate  or  from  violence  of  the  poison  ;  (19)  healthy, 
when  the  tendency  is  to  repair ;  (20)  unhealthy,  when  the 
tendency  is  to  destruction;  (21)  latent,  one  which  for  some 
time  does  not  announce  itself  by  any  obvious  symptoms, 
as  the   inflammation  of  Peyer's   patches  in   typhoid   fever; 

(22)  cojitagious,  vjh^n  its  own  secretions  can  propagate  it; 

(23)  dry,  without  exudation ;  (24)  hypostatic,  arising  in  a 
region  of  passive  congestion  (as  a  bed-sore) ;  (25)  malignant, 
due  to  malignant  growths ;  (26)  catarrhal,  affecting  mucous 
membranes ;  (27)  neuropathic ,  due  to  impairment  of  the 
trophic  functions  of  the  nervous  system,  as  in  perforating 
ulcer;  and  (28)  sympathetic  or  reflex,  due  to  injury  of  a 
distant  part,  as  when  duodenal  ulcer  follows  a  surface-burn. 

Extension  of  Inflammation. — Inflammation  extends  by 
continuity  of  structure,  by  contiguity  of  structure,  by  the 


IN  FLA  MMA  TION.  4 1 

blood,  and  by  the  lymphatics.  Extension  by  continuity  is 
seen  in  phlebitis.  Extension  by  contiguity  is  seen  when  a 
cutaneous  inflammation  advances  and  attacks  deeper  struc- 
tures. Extension  by  the  blood  is  seen  in  the  formation  of 
the  small-pox  exanthem.  Extension  by  the  lymphatics  is 
witnessed  in  a  bubo  following  chancroid. 

Terminations  of  Inflammation. — Inflammation  may  ter- 
minate in  a  return  of  the  tissues  to  health,  and  this  return 
may  take  place  by  delitescence,  by  resolution,  or  by  new 
growth.  By  delitescence  is  meant  abrupt  termination  at  an 
early  stage,  as  when  a  quinsy  is  aborted  by  quinine,  mor- 
phia, and  a  sweat ;  resolution  means  the  gradual  disappear- 
ance of  the  symptoms  when  inflammation  has  passed  through 
its  regular  stages ;  and  nei^'  growth  means  that  an  inflamma- 
tion has  had  fibrinous  exudation,  has  lasted  a  considerable 
time,  with  ample  blood-supply  and  without  suppuration. 
Inflamm^ion  may  terminate  in  death  of  the  inflamed  part, 
or  necrosis.  Death  of  the  part  may  be  due  to  suppuration, 
ulceration,  or   gangrene. 

The  causes  of  inflammation  are — predisposing,  or  those 
residing  in  the  tissues,  and  rendering  them  liable  to  inflame ; 
and  exciting,  or  those  which  directly  awake  into  activity. 
The  first  is  the  inflammable  material,  the  second  is  the  spark 
of  fire. 

Predisposing  causes  are  those  which  impair  the  general 
vigor,  injure  the  blood,  weaken  the  tissues,  or  lower  nutri- 
tive activities.  Among  these  causes  are  shock,  hemorrhage, 
nervous  irritation,  gout,  rheumatism,  diabetes,  Bright's  disease, 
and  syphilis.  Plethora  renders  a  person  liable  to  sthenic  inflam- 
mations (those  characterized  by  high  action).  Tissue-debility 
renders  one  prone  to  adynamic  or  asthenic  inflammations. 

Exciting  'Causes. — The  exciting  causes  of  inflammation 
are — traumatic,  as  blows,  etc.,  and  mechanical  irritation ; 
chemical,  as  the  stings  of  insects,  iv)-  poison,  etc. ;  tJiermal, 


42  A    MANUAL    OF  SURGERY. 

heat  and  cold  ;  and  specific^  the  micro-organisms  causing, 
for  instance,  tubercular  peritonitis  or  erysipelas. 

Symptoms. — Inflammation  announces  its  presence  by- 
symptoms  which  are  local  and  constitutional.  The  local 
symptoms  are  heat,  pain,  discoloration,  swelling,  and  dis- 
ordered function  ;  the  chief  constitutional  symptom  is  fever. 

Local  Symptomis  of  Inflammation. — The  most  promi- 
nent local  symptoms  were  known  centuries  ago  to  the 
famous  Roman  Celsus,  who  stated  them  as  "  rubor,  calor  cum 
tnnwre  ct  dolore  " — redness  and  heat  with  swelling  and  pain. 
As  set  forth  to-day,  the  local  symptoms  are — (l)heat;  (2) 
pain;  (3)  discoloration;  (4)  swelling;  and  (5)  disordered 
function. 

Heat  is  due  to  the  passage  of  an  increased  quantity  of 
blood  through  the  damac!"ed  area  and  to  increased  cellular 
activity.  Although  an  inflamed  part  may  be,  and  usually  is, 
warmer  than  the  surrounding  parts,  its  temperature  is  never 
greater  than  the  temperature  of  the  blood.  This  increase 
of  heat  is  especially  noticeable  when  we  contrast  the  feeling 
of  an  arm  affected  with  erysipelas  wnth  a  well  arm  :  the  dis- 
eased arm  feels  much  warmer,  but  still  its  temperature  is  not 
above  the  general  body-temperature.  The  extremities  in 
health,  as  is  well  known,  show  on  the  surface  a  temperature 
below  that  of  the  blood  ;  in  an  inflamed  state  their  temper- 
ature may  nearly  equal  that  of  the  blood.  Heat  is  alwa}-s 
present  in  inflammation. 

Pain  is  a  constant  and  a  conspicuous  symptom.  It  is  due 
to  stretching  of  or  pressure  upon  nerves  from  exudate ;  to 
irritation  of  nerves ;  or  to  inflammation  in  the  nerves  them- 
selves, producing  cellular  changes.  Pain  varies  in  degree 
and  in  character.  In  serous  membranes  it  is  acute  and 
lancinating,  like  dagger-thrusts ;  in  connective  tissue  it  is 
acute  and  throbbing ;  in  large  organs  it  is  dull  and  heavy ; 
in  the  bone  it  is  gnawing  or  boring;  in  the  skin  it  is  itching 


INFLAMMA  TION.  43 

or  stinging ;  in  the  urethra  it  is  scalding ;  in  the  testicle  it  is 
sickening  or  nauseating;  in  the  teeth  it  is  throbbing;  and  in 
or  under  tense  fascia  it  is  pulsatile.  Pain  may  alter  its  char- 
acter. If  a  pain  becomes  markedly  throbbing,  it  often  means 
suppuration.  Pain  does  not  always  occur  at  the  seat  of 
trouble,  but  may  be  felt  at  some  distant  point.  This  is  known 
as  a '* sympathetic"  pain,  and  means  nervous  communication, 
trouble  with  a  nerve-trunk  referring  pain  to  the  peripheral 
distribution. 

Pain  of  hepatitis  is  often  felt  in  the  right  shoulder.  This 
pain  at  the  point  of  the  shoulder  is  felt  also  in  gajl-stones 
and  in  cancer  of  the  liver.  The  pain  arises  in  filaments  of 
the  pneumogastric  from  the  hepatic  plexus,  which  filaments 
reach  the  spinal  accessory,  pain  being  expressed  in  the 
branches  of  the  spinal  accessory  which  supply  the  trapezius 
and  communicate  with  the  third  and  fourth  cervical  nerves.^ 

Pain  ef  coxalgia  is  often  felt  on  the  inside  of  the  knee, 
because  the  obturator  nei"ve,  which  sends  a  branch  to  the 
ligamentum  teres,  sends  a  branch  to  the  interior  and  to  the 
inner  side  of  the  knee-joint. 

Inflammation  of  an  eye  with  increased  tension  causes 
brow-ache.  Inflammation  of  the  neck  of  the  bladder  causes 
pain  in  the  head  of  the  penis.  Inflammation  of  a  testicle 
causes  pain  in  the  groin.  Renal  calculus  causes  pain  in  and 
retraction  of  the  testicle,  with  pain  in  the  thigh. 

If  the  covering  of  an  organ  is  involved,  pain  becomes 
more  violent ;  for  instance,  a  hepatitis  becomes  much  more 
painful  when  the  perihepatic  structures  are  attacked.  Inflam- 
mation without  pain  is  known  as  "  latent  "  (as  the  inflamma- 
tion of  Peyer's  patches  in  typhoid).  The  sudden  disappear- 
ance of  inflammatory  pain,  when  not  due  to  opiates,  means 
gangrene.  The  characteristics  of  inflammatory  pain  are  that 
it  comes  on  gradually,  has  a  fixed  seat,  is  attended  by  other 

^  Enibleton's  view  in  Hilton  on  Rest  and  Pain,  a  book  every  student  should  read. 


44  A   MANUAL    OF  SURGERY. 

inflammatory    symptoms,   and   is   increased  by   motion,   by 
pressure,  and  by  the  hanging  down  of  the  part.     If  there 
be  no  tenderness  in  a  part,  the  source  of  the  pain  is   not 
local  inflammation ;  but  tenderness  may  exist  when  there  is 
no  local  inflammation,  as  in  pain  referred  from  a  distant  part. 
Pain  not  corresponding  to  an  exact  nervous  distribution  is 
due  to  a  local  lesion.     If  pain  corresponds  exactly  to  parts 
supplied  by  a  certain  nerve,  the  cause  of  it  is  acting  on  the 
nerve-trunk   or  on   its   roots.     If  the   cutaneous   surface   is 
involved,  the   lightest  touch  causes  pain.     If  touching  the 
skin  produces  no  pain,  but  deep  pressure  does  produce  it, 
the  deeper  .structures  are  the  source.     Pain  in  muscle  and 
ligament  is  developed  by  motion :  in  muscle,  by  contraction, 
but  not  by  passive   movements  with   the   muscle   relaxed; 
in  ligament  pain  is  developed  by  active  or  passive   move- 
ments.    If,  for  example,  a  man  with  a  stiff  neck  has  pain  on 
the  right  side  of  the  back  of  his  neck  on  voluntarily  turning 
his  face  toward  the  left  shoulder,  but  is  without  pain  when 
his  face  is  turned  by  the  surgeon,  who,  conversely,  induces 
pain  by  turning  the  patient's  face  far  to  the  right,  this  con- 
dition indicates  the  trouble  to  be  muscular.     If,  however,  no 
pain  arises  on  turning  the  face  to  the  right,  but  it  is  manifest 
on  turning  the  face  actively  or  passively  to  the  left,  the  pain 
is  in  those  ligaments  which  stretch  when  the  face  is  turned 
to  the  left  (A.  Pearce  Gould). 

The  pain  of  colic  differs  from  that  of  inflammation.  It  is 
sudden  in  onset,  intermits  and  recurs  in  paroxysms,  and  is 
relieved  by  pressure.  The  pain  of  inflammation  is  gradual 
in  onset,  is  continuous,  and  is  made  worse  by  pressure.  The 
pain  of  neuralgia  is  very  paroxysmal,  comes  suddenly,  darts 
through  recognized  nerve-areas,  lasts  some  hours,  and  is  apt 
to  recur  at  a  certain  hour.  It  presents  no  general  tenderness, 
as  does  inflammation,  but  we  may  find  several  points  which 
are  acutely  sensitive  to  pressure  (Valleix's  points  douloureux). 


INFLAMMA  TION.  45 

Pain  is  of  great  value  by  calling  attention  to  parts  diseased, 
or  is  of  great  evil  by  racking  the  organism  and  even  causing 
death.  If  pain  continues,  it  becomes  in  itself  formidable  :  it 
prevents  sleep,  it  destroys  appetite,  and  it  disorders  the  mind, 
and  one  of  the  surgeon's  highest  duties  is  to  relieve  it.  The 
expression  of  physical  pain  is  one  of  heaviness,  a  fulness 
about  the  eyes  and  dropping  of  the  angles  of  the  mouth, 
added  to  appearances  due  to  anaemia,  tremor,  etc. 

Discoloration  arises  from  determination  of  blood  to  the 
part;  hence  the  more  vascular  the  tissue  the  greater  the 
discoloration.  A  non-vascular  tissue  presents  no  discolora- 
tion, though  we  find  it  adjacent  in  the  zone  of  blood-vessels 
which  bring  the  tissue  nutriment.  Discoloration  is  most 
intense  at  the  focus  or  centre  of  inflammatory  action.  Dis- 
coloration varies  in  tint  and  in  character  according  to  the 
tissue  implicated  and  to  the  nature  of  the  inflammation,  and 
it  may  be  circumscribed  or  diffuse.  Arborescent  redness 
means  a  distribution  in  dendritic  hues.  Linear  discoloration 
runs  in  straight  lines,  as  in  phlebitis.  Punctiform  discolora- 
tion occurs  in  points,  and  means  vascular  rupture.  Macu- 
liform  redness  means  resembling  an  ecchymosis  or  blotch. 

Inflammation  of  the  throat  and  skin  produces  scarlet  dis- 
coloration ;  inflammation  of  the  sclerotic  and  fibrous  coats 
of  muscles  produces  lilac  or  bluish  discoloration  ;  inflamma- 
tion of  the  iris  produces  brick-dust,  grayish,  or  brown  dis- 
coloration ;  erysipelas  causes  a  yellowish-red  discoloration  ; 
secondary  syphilis  causes  a  copper-hued  discoloration ;  and 
tonsillitis  causes  a  livid  discoloration.  A  scrofulous  ulcer  is 
of  a  purple  color  on  the  edge.  Gangrene  is  shown  by  a 
black  discoloration. 

Redness  as  a  sign  of  inflammation  must  be  permanent 
and  joined  with  other  symptoms.  Redness  due  to  inflam- 
mation disappears  on  pressure,  but  returns  as  soon  as  the 
pressure  is  removed.     If  redness  is  due  to  staining  of  the 


46  A   MANUAL    OF  SURGERY. 

surface,  pigmentation,  or  extravasation,  pressure  will  not 
blanch  the  spot.  If  on  taking  off  pressure  the  redness  of 
inflammation  rapidly  returns,  the  circulation  is  active;  if,  on 
the  contrary,  it  very  slowly  reappears,  the  circulation  is  very 
sluggish  and  gangrene  may  occur. 

Swcliifig  or  tumefaction  arises  in  small  part  from  vascular 
distention,  but  chiefly  from  effusion  and  cell-multiplication. 
The  more  loose  cellular  material  a  part  contains,  the  more  it 
swells;  hence  the  eyelids,  scrotum,  vulva,  tonsils,  glottis, 
and  conjunctiva  swell  very  largely  when  inflamed.  A  swell- 
ing may  be  soft  or  oedematous,  due  to  serous  effusion,  or  it 
may  be  hard  and  elastic,  due  to  embryonic  tissue.  Swelling 
may  do  good  by  unloading  the  vessels  and  acting  like  a 
blister  or  local  bleeding,  or  it  may  do  great  harm  by  press- 
ing upon  the  vessels  and  cutting  off  the  blood-supply. 
Swelling  of  the  conjunctiva,  or  chemosis,  may  cause  slough- 
ing of  the  cornea,  and  swelling  of  the  prepuce  can  cause 
gangrene.  A  swelling  may  do  harm  by  obstruction,  as  in 
oedema  of  the  glottis,  or  by  compression,  as  of  the  urethra, 
by  the  swelling  of  the  perineum. 

Disordered  function  is  always  present  in  inflammation. 
It  may  be  manifested  by  increased  tenderness  or  sensibility, 
a  slight  touch,  it  may  be,  producing  torturing  pain.  Parts 
almost  or  entirely  destitute  of  feeling  when  healthy  (as  ten- 
dons, ligaments,  and  bones)  become  highly  sensitive  when 
inflamed.  In  increased  irritability  in  d)'sentery  the  colon 
constantly  contracts  and  expels  its  contents ;  the  stomach 
does  likewise  in  gastritis  ;  and  the  bladder  also  in  cystitis. 
Spasmodic  twitching  of  the  eyelids  occurs  in  conjunctivitis, 
and  twitching  of  the  muscles  in  fracture  and  after  amputation. 

Impairment  of  Special  Function. — In  inflammations  of  the 
eye  objects  cannot  be  looked  at,  the  lids  closing  spasmodi- 
cally ;  even  a  little  light  causes  great  pain  and  lachrymation 
(photophobia).     In   inflammations   of  the  ear  noises   cause 


INFLAMMA  T/ON.  47 

great  suffering,  and  even  in  quiet  the  patient  has  subjective 
buzzing  and  roaring  sounds  in  his  ears  (tinnitus  aurium). 
In  coryza  the  sense  of  smell,  and  in  glossitis  the  sense  of 
taste,  is  lost;  and  in  dermatitis  the  sertse  of  touch,  and  in 
laryngitis  the  voice,  may  be  lost.  In  inflammation  of  the 
brain  the  mind  is  lost;  in  arthritis  the  joints  can  scarcely 
if  at  all  be  used ;  and  in  myositis  to  employ  the  muscles  is 
difficult  and  painful. 

Dcrangemejit  of  Secretions. — In  dermatitis  the  sweat  is  not 
thrown  off;  in  hepatitis  bile  is  not  secreted ;  and  in  nephritis 
urine  is  not  properly  removed.  The  secretions  may  undergo 
important  changes  of  composition.  Pneumonia  causes  rusty 
sputum,  and  dysentery  causes  bloody  mucus  (Gross). 

Derangement  of  Absorbents. — In  the  height  of  an  inflam- 
mation the  absorbents  are  blocked  and  clogged  by  coagulable 
lymph,  and  they  cannot  perform  their  offices. 

Constitutional  symptoms  of  inflammation  may  be  ab- 
sent, and  often  are  in  moderate  or  limited  inflammations,  but 
in  severe  extensive  or  infective  inflammations  we  eet  the 
compound  symptom  fever.  This  is  known  as  symptomatic, 
sympathetic,  or  inflammatory  fever,  and  it  arises  in  non- 
septic  cases  from  the  absorption  of  pyogenous  exudate. 
In  inflammation  with  fever  the  proportion  of  fibrin  in  the 
blood  rises  from  4  in  1 000  to  at  least  8  in  lOOO.  The  fibrin 
ferment  is  contained  in  the  white  corpuscles ;  it  is  liberated 
as  the  corpuscles  break  up  in  the  exudate,  and,  acting  on 
the  liquor  sanguinis,  forms  fibrin.  Inflammatory  blood  con- 
tains an  increased  amount  of  albumen  and  salts.  If  a  person 
with  inflammatory  fever  is  bled,  the  blood  coagulates  rapidly, 
the  clot  sinks,  and  there  is  found  on  the  surface  a  cup-shaped 
coat,  made  up  of  liquor  sanguinis  and  white  cells,  known  as 
the  "  buffx'  coat." 

Treatment  of  Inflammation. — In  treating  an  inflamma- 
tion there  must  first  be  removed  the  exciting  cause.     If  this 


48  ^1    MAXUAL    OF  SURGERY. 

is  from  a  splinter  in  the  part,  it  must  be  taken  out;  if  from 
a  foreign  body  in  the  eye,  it  must  be  rem.oved ;  if  urine  is 
extravasated,  open. and  drain;  take  off  pressure  from  a  corn; 
and  pull  out  an  ingrown  nail.  After  removing  the  cause, 
endeavor  to  bring  about  a  cure  by  local  and  constitutional 
treatment. 

Local  Treatment  of  Inflamination. — It  must  be  remem- 
bered that  the  division  of  inflammation  into  stages  is  natural, 
and  not  artificial,  and  that  a  remedy  which  does  good  in  one 
stage  may  do  harm  in  another.  Certain  agents  are  suited 
to  all  stages  of  an  inflammation,  namely,  rest  and  elevation. 

Rest  is  of  infinite  importance,  and  is  always  indicated  in 
inflammation.  Its  principles  were  first  thoroughly  studied 
by  Hilton.^  The  means  of  securing  rest  differ  with  the 
structure  or  the  organ  diseased,  but  when  rest  is  used,  do 
not  employ  it  too  long.  In  cerebral  concussion  rest  must  be 
secured  by  quiet,  by  darkness,  by  the  avoidance  of  stimu- 
lants and  meat,  by  the  application  of  ice  to  the  head,  and 
by  the  use  of  purgatives  to  prevent  reflex  disturbance  and 
the  circulation  of  poisons  in  the  blood.  In  inflamed  joints 
rest  must  be  obtained  by  proper  position  coupled  with  splints, 
plaster,  or  extension. 

Muscular  relaxation  is  a  valuable  form  of  rest.  In  pleurisy 
partial  rest  can  be  secured  by  strapping  the  affected  side  or 
by  using  a  bandage  or  a  binder  to  limit  respiratory  move- 
ments. In  fractures  Nature  procures  rest  by  a  splint — the 
callus — and  the  surgeon  procures  rest  by  splints,  immovable 
dressings,  or  extension.  In  fractures  of  the  ribs,  strap  the 
chest  on  the  injured  side.  In  cancer  of  the  rectum  a  colos- 
tomy secures  rest  for  the  damaged  bowel.  In  enteritis  opium 
gives  rest  to  the  bowel  by  stopping  peri.stalsis.  In  cystitis 
rest  is  obtained  by  opium  and  belladonna,  which  paralyze 
the   muscular  fibres   of  the  bladder.     A   cystotomy  allows 

^  Lectures  upon  Rest  mid  Pain. 


I  NFL  A  ALMA  TLON. 


49 


complete  rest  by  permitting  the  bladder  to  suspend  its 
function  as  a  reservoir  of  urine.  In  vesical  calculus  rest  is 
obtained  by  cutting  or  crushing  the  stone.  In  inflained 
imicous  incnibraiics  rest  is  secured  (from  the  contact  of  irri- 
tants) by  touching  them  with  silver  nitrate,  which  forms 
a  protective  coat  of  coagulated  albumen.  Opening  an 
abscess  gives  its  walls  rest  from  tension.  In  inflainmations 
of  the  eye  light  should  be  excluded.  In  aucurisin  the  opera- 
tion cuts  off  the  blood-current  and  gives  rest.  In  licniia 
the  operation  gives  rest  from  pressure.  Instances  of  the 
methods  of  using  rest  could  indefinitely  be  multiplied. 

Elevation  partly  restores  circulatory  equilibrium.  A  felon 
is  less  painful  when  the  hand  is  held  up  in  a  sling  than  when 
it  is  dependent.  A  congestive  headache  is  worse  during  re- 
cumbency. A  gouty  inflammation  in  the  great  toe  is  more 
painful  with  the  foot  lowered  than  w^ith  it  raised.  A  tooth- 
ache  becomes  worse  on  lying  dowm. 

Relaxation  is  in  reality  a  form  of  rest,  and  consists  in 
placing  the  part  in  an  easy  position.  In  synovitis  of  the 
knee  semiflexion  of  the  knee-joint  lessens  the  pain.  In 
muscular  inflammations  relaxation   relieves  the  pain. 

Certain  agents  are  suited  to  the  stage  of  vascular  engorge- 
ment, increased  arterial  tension,  and  beginning  effusion. 
These  agents  are — (i)  local  bleeding  or  depletion  ;  (2)  cutting 
off  the  blood-supply  ;  and  (3)  cold. 

Local  bleeding  or  depletion  is  the  abstraction  of  blood  from 
the  inflamed  area.  This  abstraction  relieves  circulatory  re- 
tardation and  causes  the  blood  to  move  rapidly  onward  ; 
the  corpuscles  clinging  to  the  vessel-walls  are  washed  away, 
the  capillaries  shrink  to  their  natural  size,  and  the  exudate 
is  absorbed.  In  other  words,  local  blood-letting  increases 
the  rate  of  the  circulation,  though  not  its  force. 

TJie   methods   of  bleeding  locally   are — {(.i)   puncture;   f^) 
scarification;   (r)  leeching;   and  {d)  cupping. 
4 


50  A   MANUAL    OF  SURGERY. 

Puncture  is  rcconi mended  in  inflatnniation,  not  only 
because  it  abstracts  blood  locally,  but  also  because  it  gives 
an  exit  to  effusion  under  fibrous  membranes.  It  is  very  use- 
ful in  relieving  tension,  as  in  epididymitis.  It  is  performed 
with  a  tenotome  and  with  aseptic  precautions.  If  punctures 
are  made  in  numerous  places,  the  procedure  is  termed 
"  multiple  puncture."  This  is  very  useful  when  applied  to 
the  inflamed  area  around  a  leg-ulcer. 

Scarification  or  Incision. — By  means  of  scarification  we 
bleed  locally,  evacuate  exudates,  and  relieve  tension.  We 
may  make  one  cut  or  many  cuts,  which  may  be  deep  or 
may  not  even  go  entirely  through  the  skin,  according  to 
circumstances.  Multiple  incision  is  applied  to  inflamed 
ulcers,  ulcers  in  danger  of  gangrene,  and  almost  any  con- 
dition of  great  tension. 

.  Leeching. — Leeches  must  not  be  applied  to  a  region  plen- 
tifully endowed  with  loose  cellular  tissue,  as  great  swelling 
and  discoloration  are  sure  to  ensue.  These  regions  are  the 
prepuce,  labia  majora,  scrotum,  and  eyelids.  Leeches  should 
never  be  applied  to  the  face  (because  of  the  scar),  near 
specific  scars  or  inflammations,  nor  over  a  superficial  artery, 
a  vein,  or  a  nerve.  A  leech  is  best  applied  at  the  periphery 
of  an  inflammation  or  between  an  inflammation  and  the 
heart.  To  leech  at  the  inflammatory  focus  only  aggravates 
the  case.  Before  applying  leeches,  wash  the  part  and  shave 
it  if  hairy.  If  the  leeches  will  not  bite,  smear  the  part  with 
milk  or  with  a  little  blood.  In  using  a  leech,  place  it  on 
the  skin  under  a  glass  tube  or  an  inverted  wine-glass.  Never 
pull  off  a  leech  :  let  it  drop  off;  and  if  it  refuses  to  do  so, 
sprinkle  it  with  salt.  After  removing  a  leech,  employ  warm 
fomentations  if  continued  bleeding  is  desired.  Sometimes 
the  bleeding  persists,  but  this  may  be  arrested  by  styptic 
cotton  and  pressure.  Leeching  leaves  permanent  triangular 
scars.     The  Swedish  leech,  which  is  preferred  to  the  Ameri- 


INFLAMMA  TION.  5 1 

can,  draws  from  four  to  six  drachms.  Leeching  has  both  a 
constitutional  and  a  local  effect.  It  is  now  used  compara- 
tively rarely,  but  it  is  of  value  over  the  spermatic  cord  in 
epididymitis,  and  on  the  temple  in  ocular  inflammation. 
Occasionally  the  neck  of  the  womb  is  leeched  by  holding 
the  leech  against  it  in  a  test-tube. 

Clipping:  Wet  Cups. — In  wet  cupping,  apply  a  cup  for 
a  moment,  remove  and  incise  or  puncture,  and  apply  it 
again  to  draw  the  requisite  amount  of  blood.  Baron  Heur- 
teloup  devised  an  instrument  (Fig.  18)  in  which  the  incision 


Fig.  18. — Heurteloup's  Artificial  Leech  (Tiemann). 

is  made  by  a  scarifier.  The  blood  is  drawn  by  a  pump,  the 
tube  being  placed  upon  the  cut  area  and  the  withdrawal 
of  the  piston  creating  a  vacuum.  This  instrument  is  known 
as  the  ''  artificial  leech."  Wet  cupping  is  of  value  in  pneu- 
monia, pleurisy,  pericarditis,  and  nephritis. 

Cutting  off  the  Blood-supply. — Onderdonk  of  New  York 
in  1 813  recommended  ligation  of  the  main  artery  of  a  limb 
for  the  cure  of  inflammation  in  important  structures  which 
it  supplied.  This  procedure  was  warmly  advocated  by 
Campbell  of  Georgia  for  the  treatment  of  gunshot  wounds 
of  joints.  This  plan  of  treatment  is  now  not  to  be  considered 
for  a  moment ;  antisepsis  furnishes  us  with  a  safer  and  more 


52 


A   MANUAL    OF  SURGERY. 


certain  plan.     Vanzetti  of  Padua  advocates  digital  pressure 
to  cut  off  the  blood-supply  to  an  inflamed  part. 

Cold  is  a  very  powerful  and  an  extremely  useful  agent. 
It  constringes  the  vessels,  prevents  migration  of  corpuscles, 
favors  the  absorption  of  exudate,  retards  cell-proliferation, 
and  relieves  pain,  swelling,  and  tension.  Cold  must  not  be 
applied  to  the  old  or  to  the  feeble,  as  it  may  induce  gan- 
orene.  It  is  harmful  in  advanced  inflammations  or  severe 
congestions  (as  strangulated  her- 
nia). There  are  two  forms  of  cold, 
the  dry  and  the  wet. 

IVct  Cold. — To  apply  the  wet 
cold,  the  part  is  wrapped  in  wet 
linen  or  muslin  and  laid  upon  a 
rubber  sheet  folded  like  a  trough 
and  emptying  into  a  bucket,    A 


Fig.  19. — Siphon  (Esmarch). 


vessel  filled  with  cold  water  is  placed  upon  a  higher  level 
than  the  bed.  A  wet  lamp- wick  is  now  taken,  one  end  is 
inserted   into   the  water  of  the  vessel,   and   the   other  end 


INFLAMMA  TIOiV. 


53 


is  laid  upon  the  part.  Capillary  action  and  gravity  combine 
to  keep  the  part  moist  (Fig.  19).  Ordinary  water  or  iced 
water  can  be  used.  If  the  water  be  too  warm,  it  can  be 
reduced  to  about  45°  F.  by  adding  i  part  of  alcohol  to  every 

4  parts  of  water.     A  mixture  of  5  parts  of  nitrate  of  potash, 

5  parts  of  chloride  of  ammonium,  and  16  parts  of  water 
produces  great  cold.  If  we  use  wet  cold  upon  an  open 
wound,  the  fluid  should  be  antiseptic.  Wet  cold  is  now  not 
often  used  to  irrigate.  It  is  applied  in  severe  conjunctivitis 
by  means  of  cloths  soaked  in  ice- water  and  frequently  changed. 
Evaporating  lotions  owe  a  portion  of  their  efficacy  to  the 
cold  they  induce. 

Dry  cold  is  applied  by  means  of  a  rubber  bag  or  a  blad- 
der filled  with  ground  or  finely-cracked  ice,  several  folds  of 


Fig.  20. — The  Esmaich  Cooling  Coil  (Esmarch) 


flannel  being  first  laid  over  the  part.  A  part  can  be  encircled 
with  a  rubber  tube  through  which  ice-water  is  made  to  flow 
(Fig.  20).     Leiter's   tubes,  which   are   made   to  fit  various 


54  A   MANUAL    OF  SURGERY. 

regions  and  which  cany  a  stream  of  cold  water,  can  also  be 
used.  An  ice-bag,  if  applied  at  once,  is  the  best  treatment 
for  a  strained  joint.  Ice-bags  are  very  useful  in  acute 
myelitis,  meningitis,  joint-inflammations,  epididymitis,  and 
other  acute  inflammations  in  the  early  stage. 

Certain  agents  are  suited  to  the  stage  of  fully-developed 
inflammation,  when  we  have  a  great  deal  of  swelling  due  to 
effusion  and  cell-proliferation.  The  indication  in  this  stage 
is  to  abate  swelling  by  promoting  absorption.  This  is 
accomplished  by  (i)  compression  ;  (2)  the  local  use  of  astrin- 
gents and  sorbefacients ;  (3)  the  douche ;  (4)  massage ;  and 
(5)  intermittent  heat. 

Compression  is  the  agent  especially  used  in  fully-developed 
and  in  chronic  inflammation,  but  it  will  do  good  as  well  in 
the  first  stage.  Compression  is  of  great  usefulness  :  it  sup- 
ports the  vessels  and  causes  them  to  drink  up  effusion,  and 
strongly  rouses  the  absorbents.  This  agent  is  valuable  in 
rriost  external  inflammations  with  much  swelling.  In  ery- 
sipelas of  an  extremity,  besides  the  use  of  elevation  and 
drugs,  bandage  the  extremity  from  the  periphery  to  the 
body.  In  ulcers,  especially  those  with  hard  and  blue  edges, 
use  the  Martin  elastic  bandage  or  strap  with  plaster.  In 
chronic  inflammation  of  a  joint  elastic  compression  is  of 
great  value.  In  epididymitis,  after  the  acute  stage,  strap  the 
testicle  with  adhesive  plaster.  In  lymphadenitis  use  com- 
pression by  a  weight  or  by  a  bandage.  In  fractures  com- 
pression not  only  antagonizes  spasm,  but  also  combats  the 
swelling  and  pain  of  inflammation.  Compression  must  be 
judicious:  it  must  never  be  too  hard,  and  it  must  not  be 
applied  to  a  limb  without  including  the  extremity  of  it  (never, 
for  instance,  strongly  compress  the  elbow  without  including 
the  hand,  nor  the  palm  without  bandaging  the  fingers). 

Astringents  and  Sorbefacients:  Solittiois  of  Acetate  of 
Lead. — Ammonium  chloride  was  formerly  employed  in  the 


INFLAMMA  TTON.  5  5 

strength  of  5J  to  2  quarts  of  water,  but  if  long  used  it  pro- 
duces pustules  and  thus  causes  irritation  and  pain.  A  solu- 
tion of  the  acetate  of  lead  is  astringent  and  sorbefacient ; 
it  promotes  the  contraction  of  distended  vessels,  accelerates 
the  blood-current,  and  urges  the  absorbents  to  increased 
activit)'.  This  agent,  in  practice,  is  usually  mixed  with  lauda- 
num, as  follows  :  Laudanum,  f5J  ;  liquor  plumbi  subacetatis, 
foj  ;  aquae.  Oj.  This  solution,  spoken  of  as  lead-water  and 
laudanum,  is  extensively  used  and  is  very  soothing.  It  can 
be  employed  cold,  the  evaporation  which  it  undergoes  cool- 
ing the  part.  It  is  best  applied  by  soaking  a  double  layer 
of  flannel  in  the  lead-water,  la3nng  it  on  the  affected  part, 
and  by  means  of  a  sponge  squeezing  more  of  the  lotion  upon 
it  from  time  to  time.  If  it  is  desired  to  have  it  very  cold, 
an  ice-bag  can  be  placed  upon  the  soaked  flannel.  Lead- 
water  and  laudanum  may  be  used  warm,  the  flannel  being 
covere<^  with  oiled  silk  or  waxed  paper.  If  it  is  desired 
hot  (veritably  a  poultice),  lay  upon  the  flannel  a  hot-water 
bag.     Lead-water  is  not  used  in  treating  open  wounds. 

Tincture  of  iodine  acts  like  lead  acetate.  It  must  not  be 
used  pure,  but  diluted  for  adults  with  an  equal  part  of  alco- 
hol, and  for  children  with  3  parts  of  alcohol.  In  using 
iodine,  paint  it  on  with  a  camel's-hair  brush  and  fan  it  dry, 
applying  one  or  more  coats.  The  repeated  application  of 
iodine  to  the  skin  is  of  great  benefit  in  inflammation  of  the 
glands,  muscles,  tendons,  joints,  and  about  ulcers  and  peri- 
osteal structures  ;  it  is  apt,  after  a  time,  to  vesicate,  and  must 
not  be  used  in  treating  open  wounds. 

Nitrate  of  silver  is  a  non-irritating  astringent  of  great 
value  in  inflammation  of  mucous  membranes.  It  forms  a 
protective  coat  of  coagulated  albumen,  and  is  much  used 
in  treating  the  throat,  mouth,  and  genital  organs. 

IcJitJiyol  is  a  drug  of  wonderful  efficacy  in  reducing  in- 
flammatory swelling.     It  is  usually  employed  in  ointments 


56  A   MANUAL    OF  SURGERY. 

of  a  strcngtli  of  from  25  to  50  per  cent.  It  is  best  exhibited 
with  lanolin.  In  acute  rheumatism  it  can  be  rubbed  upon 
the  joints,  and  in  lymphatic  enlargements  it  is  of  great  value. 
In  children  a  25  per  cent.,  and  in  adults  a  50  per  cent.,  oint- 
ment is  well  rubbed  in  twice  a  day.  In  inflammatory  skin 
disease,  synovitis,  thecitis,  frost-bite,  bubo,  chilblain,  and  in 
many  other  conditions  it  is  indicated.  The  odor  of  ichthyol 
is  highly  disagreeable,  and  when  ordered  for  a  refined  person 
it  had  better  be  deodorized.  For  this  purpose  Hare  uses  oil 
of  citronella,  TTLxx  to  5J  of  ointment. 

Mercurials. — Blue  ointment,  pure  or  diluted  to  various 
strengths,  is  valuable  to  a  high  degree.  It  is  spread  uj)on 
lint  and  kept  applied  over  inflamed  joints,  glands,  tendons, 
etc.  Blue  ointment  is  strongly  irritant,  and  will  soon  blister 
or  excoriate  a  tender  skin.  It  is  very  beneficial  in  perios- 
titis, and  is  employed  largely  in  chronic  inflammations. 

The  douche  consists  of  a  stream  of  water  falling  upon 
a  part  from  a  height.  The  water  may  be  poured  from  a 
receptacle  or  may  run  through  a  tube,  and  may  either  be 
hot  or  be  cold.  Alternating  hot  and  cold  streams  are  very 
popular  in  chronic  inflammations  of  joints  and  tendons,  and 
they  constitute  the  "Scotch  douche."  In  a  strain  of  the 
knee,  for  instance,  where,  after  a  time,  thickening  has  oc- 
curred, pour  upon  the  part  daily,  from  a  height,  first  a 
pitcherful  of  very  hot  water,  then  a  pitcherful  of  very  cold 
water  ;  then  use  friction  with  a  hand  greased  with  cosmoline. 
The  douche  acts  by  restoring  vascular  tone  and  by  promot- 
ing the  action  of  the  absorbents.  Hot  vaginal  douches  are 
largely  employed  in  pelvic  inflammations. 

Intermittent  heat  finds  an  example  in  the  use  of  very  hot 
water  in  a  strained  and  badly-swollen  ankle  by  plunging 
the   foot  in  a  bucket  of  hot  water  several  times  a  day. 

Massage  is  a  procedure  not  frequently  enough  employed. 
It   is   powerful    for   good    in   chronic    inflammations   at  the 


I  NFL  A  AT  MA  TION.  5  7 

period  where  rest  is  abandoned.  It  acts  by  promoting  the 
movements  of  tissue-fluids  (blood,  lymph,  and  areolar  fluid), 
stimulating  the  absorbents,  strengthening  local  nervous  con- 
trol, and  thus  improving  nutrition.  Passive  motion  in  joints 
acts  as  massage. 

Heat. — Certain  agents  are  indicated  when  suppuration  is 
threatened,  these  agents  being  the  various  forms  of  heat. 
Heat  increases  the  mobility  of  the  white  corpuscles,  increases 
their  migration,  relieves  stasis  and  thus  tension,  promotes 
tissue-change  and  microbic  action,  and  favors  suppuration. 
Continuous  heat  may  be  used  earlier  in  an  inflammation,  as 
in  the  first  stage  of  a  pneumonia,  but  it  is  so  used  only  in  a 
deep-seated  trouble,  and  acts  purely  as  a  revulsive,  dilating 
the  superficial  vessels  and  helping  to  empty  the  deeper  ones. 

T\\^  fonns  of  heat  are — (i)  fomentations;  (2)  poultices; 
(3)  water-bath  ;    and  (4)  dry  heat. 

FoiJientations. — A  fomentation  is  the  application  of  a  liquid 
to  the  surface  of  the  body  on  sponges  or  other  material. 
To  apply  a  fomentation,  wring  out  a  piece  of  flannel  in  hot 
water,  lay  it  upon  the  part,  and  cover  it  with  oiled  silk 
or  with  waxed  paper,  changing  it  as  soon  as  it  begins  to 
cool.  The  flannel  which  is  dipped  into  the  hot  liquid  is 
known  as  a  "  stupe."  The  turpentine  stupe  is  made  by 
wringing  out  the  flannel  as  above  and  then  putting  upon  it 
from  10  to  20  drops  of  turpentine.  Instead  of  fomenting 
the  part,  steam  may  be  thrown  upon  it.  Fomentations  are 
used  chiefly  for  the  reflex  influence  over  deep  congestions 
or  inflammations.  The  liquid  of  a  fomentation  may,  if 
desired,  contain  corrosive  sublimate,  carbolic  acid,  or  other 
agents. 

Poultice  or  Cataplasm. — A  poultice  is  a  soft  mushy  mass 
applied  to  a  part  to  bring  heat  and  moisture  to  bear  upon 
it.  Poultices  are  preferably  made  of  ground  flaxseed  or 
of  slippery-elm  bark,  but  they  can  be  made  of  arrowroot, 


58  A   MANUAL    OF  SURGERY. 

starch,  bread  and  milk,  potatoes,  turnips,  etc.  To  make  a 
flaxseed  poultice,  scald  a  spoon  and  a  tin  basin,  put  the 
flaxseed  into  the  dry  hot  basin,  and  pour  upon  it  boiling 
water  in  sufficient  quantity  to  form  a  thick  paste.  The 
proper  consistence  is  found  when  the  mass  would  stick  to, 
if  it  were  thrown  against,  a  wall.  It  is  now  spread  upon 
a  piece  of  muslin  to  the  thickness  of  a  quarter  of  an  inch, 
and  covered  with  a  bit  of  gauze  or  mosquito-net  to  prevent 
its  adhesion  to  the  skin.  Flaxseed  retains  heat  a  lono-  time, 
and  it  needs  to  be  changed  only  every  five  or  six  hours. 
The  poultice  should  be  covered  outside  with  oiled  silk  or 
with  waxed  paper.  Spongiopiline  is  a  good  substitute  poul- 
tice. Lint  soaked  with  hot  water  and  covered  with  some 
impermeable  material  does  very  well.  The  fermented  poul- 
tice, which  was  once  popular  for  gangrenous  ulcers,  was 
made  by  sprinkling  yeast  upon  an  ordinary  cataplasm.  The 
charcoal  poultice  is  made  by  stirring  charcoal  into  the  usual 
poultice  mass.  A  poultice  containing  opium  is  known  as 
a  "sedative."  About  gr.  ij  of  opium  to  the  ounce  of  poul- 
tice mass  relieves  pain.  An  antiseptic  poultice  is  made  by 
partly  wringing  out  gauze  in  a  hot  solution  of  corrosive  sub- 
limate (i  :  looo),  covering  it  with  oiled  silk,  and  placing  a 
hot-water  bag  upon  it  to  maintain  the  heat.  Poultices  must 
not  be  kept  on  too  long,  as  they  will  then  vesicate,  especially 
in  adynamic  conditions.  If  a  poultice  is  found  to  be  vesicat- 
ing, sprinkle  it  with  powdered  oxide  of  zinc.  A  wound 
should  never  be  poulticed  except  by  the  antiseptic  method. 

Water-batli. — The  continuous  hot  bath  is  now  rarely  em- 
ployed except  in  cases  of  phagedsena,  when  it  often  proves 
curative.  The  water  should  in  these  cases  contain  bichloride 
of  mercury. 

Dry  heat  is  applied  by  a  metallic  object  dipped  in  hot 
water  and  laid  upon  the  part ;  by  Leiter's  tubes,  through 
which  hot  water  flows ;    or  by  the  hot-v/ater  bag. 


INF  LAM  MA  TION.  5  9 

Irritants  and.  Counter-irritants  iJi  luflannnation. — Irritants 
cause  an  increased  supply  of  blood  to  the  part  where  they 
are  applied  ;  in  other  words,  they  are  used  for  their  local 
effects.  Counter-irritants  are  used  to  affect  by  reflex  influence 
some  distant  part.  In  chronic  inflammation  irritants  may 
do  good  by  promoting  the  blood-supply,  thus  favoring  the 
removal  of  exudates  (liniments  in  rheumatism  and  synovitis, 
and  nitrate  of  silver  in  ulcers).  Counter-irritants  are  power- 
ful pain  relievers  when  used  over  an  inflamed  part ;  they 
bring  blood  to  the  surface  and  cause  anaemia  of  internal 
parts,  the  site  and  area  of  anaemia  depending  on  the  site,  the 
area,  and  the  duration  of  the  surface  irritation.  To  strongly 
counter-irritate  too  near  an  inflammation  is  harmful  instead 
of  beneficial.  (Do  not  blister  for  pericarditis  directly  over 
the  pericardium. — Brunton).  Counter-irritants  not  only  re- 
lieve pain  and  congestion  in  the  earlier  stages  of  inflamma- 
tion, but  they  also  promote  absorption  of  exudate  in  the 
later  stages.  This  is  seen  in  blistering  old  thickened  ulcers, 
and  in  painting  the  chest  with  iodine  to  relieve  pleuritic 
effusion.  Frictions,  besides  their  pressure-effects,  act  as 
counter-irritants.  Frictions  may  relieve  skin-pain,  and  are 
associated  with  stimulating  liniments  in  stiff  joints. 

There  is  no  more  efficient  method  of  relieving  pleural 
effusion  than  by  a  succession  of  blisters.  They  are  used  in 
inflamed  joints,  pericarditis,  pneumonic  consolidation  of  the 
lung,  acute  and  chronic  rheumatism,  etc.,  and  back  of  the 
ears  or  at  the  nape  of  the  neck  in  congestive  coma  or 
meningitis.  A  blister  can  be  obtained  in  a  few  minutes  by 
soaking  a  bit  of  lint  in  chloroform,  and,  after  applying  it  to 
the  surface,  covering  it  first  with  oiled  silk,  and  then  with 
a  watch-glass.  Equal  parts  of  lard  and  ammonia  will  blister 
in  five  minutes.  It  is  more  usual  to  blister  with  cantharidal 
collodion  or  blistering-paper.  Before  applying  a  blister, 
shave  the  part  if  it  be  hairy ;  then  apply  the  plaster,  which 


6o  A   MANUAL    OF  SURGERY. 

is  left  on  six  hours  in  the  case  of  an  adult,  but  only  two 
hours  in  the  case  of  an  old  person  or  a  child ;  the  plaster  is 
then  removed,  and  if  a  blister  is  not  formed,  the  part  must 
be  poulticed  for  a  few  hours.  When  a  blister  is  obtained, 
open  it  with  a  clean  needle.  If  it  be  desired  to  heal  the 
blister,  grease  it  with  cosmoline  or  with  zinc  ointment.  If 
it  is  to  remain  open,  dress  it  with  from  4  to  6  drops  of 
nitric  acid  to  the  ounce  of  cosmoline  after  cutting  away  the 
stratum  corneum. 

We  can  pustulate  with  tartar-emetic  ointment,  with  the 
hot  iron,  or  with  Vienna  paste.  Tartar-emetic  ointment  was 
formerly  used  on  the  scalp  in  meningitis.  To  pustulate 
with  the  hot  iron,  use  it  at  a  white  heat,  lay  it  on  the  part, 
and,  after  using  iced-water  cloths  for  an  hour  or  two, 
employ  a  poultice.  The  hot  iron  is  the  most  powerful  of 
counter-irritants,  and  is  used  for  joint-inflammations,  bone- 
diseases,  and  inflammations  of  the  spinal  cord.  Vienna  paste 
consists  of  5  parts  of  caustic  potash  and  6  parts  of  lime 
made  into  a  paste  with  alcohol.  It  is  applied  for  five  min- 
utes, and  is  then  washed  off  with  vinegar. 

Constitutional  Treatment  of  Inflammation. — Certain 
remedies  are  used  in  inflammation  for  their  general  or  con- 
stitutional effects;  these  remedies  are — (i)  general  bleeding; 
(2)  arterial  sedatives;  (3)  cathartics;  (4)  diaphoretics;  (5) 
diuretics;  (6)  anodynes;  (7)  antipyretics;  (8)  emetics;  (9) 
mercury  and  iodides;   (10)  stimulants;   and  (11)  tonics. 

General  bleeding,  veneseetion,  or  phlebotomy  is  suited  to  the 
early  stages  of  an  acute  inflammation  in  a  young  and  robust 
man.  The  indication  for  its  employment  is  increased  arterial 
tension,  as  shown  by  a  strong,  full,  rapid,  and  incompressible 
pulse  in  a  vigorous  young  patient.  General  blood-letting  di- 
minishes blood-pressure  and  increases  the  speed  of  the  blood- 
current,  thus  amending  stasis,  absorbing  exudate,  and  wash- 
ing adherent  corpuscles  from  the  vessel-wall ;  furthermore, 


INFLAMMA  TION.  6 1 

it  reduces  the  whole  amount  of  bodv-blood,  thus  forcing 
a  greater  rapidity  of  circulation,  decreases  the  amount  of 
fibrin  and  albumen,  lowers  the  temperature,  arrests  cell-pro- 
liferation, and  stops  the  effusion  of  lymph. 

This  procedure  was  in  former  days  so  highly  esteemed 
that  it  settled  into  a  routine  formula  to  be  applied  to  every 
condition  from  yellow  fever  to  dislocation.  The  terrible 
mortality  of  the  cholera  epidemics  from  1830  to  1835  led 
practitioners  to  question  whether  bleeding  was  or  was  not 
a  general  panacea,  and  from  this  doubt  there  was  born  in 
the  next  generation  violent  opposition  to  blood-letting  in 
any  disease.  Like  most  reactions,  opposition  has  gone  too 
far,  the  pendulum  of  condemnation  has  swung  beyond  the 
line  of  truth  and  sense,  and  thus  is  universally  neglected  or 
broadly  condemned  one  of  the  most  powerful  and  valuable 
of  resources.  Many  physicians  of  long  experience  have  never 
seen  a  person  bled ;  its  performance  is  not  demonstrated  in 
most  schools,  and  but  few  patients  and  families  will  permit 
it  to  be  done.  But  when  properly  used  it  is  invaluable. 
It  is  only  applicable,  however,  to  the  young,  strong,  and 
robust,  and  not  to  the  old,  weak,  or  feeble.  It  is  used  in 
violent  acute  inflammations  of  important  organs  or  tissues, 
and  not  for  low  inflammations  or  for  slight  affections  of 
unimportant  parts.  It  is  used  in  the  early,  but  not  in 
the  late,  stages  of  an  inflammation.  It  is  used  when  the 
pulse  is  frequent,  full,  hard,  and  incompressible,  but  not 
when  it  is  slow,  small,  soft,  compressible,  and  irregular. 
It  is  used  when  the  face  is  flushed,  but  not  when  it  is  pal- 
lid. It  is  not  used  in  fat  persons,  drunkards,  very  nervous 
people,  or  the  sufferers  from  adynamic,  septic,  or  epidemic 
diseases.  It  is  of  infinite  value  in  congestion  of  the  lungs, 
pneumonia,  pleurisy,  meningitis,  prostatitis,  cystitis,  and 
other  acute  inflammatory  conditions. 

Blood  is  usually  taken  from  the  median  cephalic  vein,  the 


62  A   MANUAL    OF  SURGERY. 

incision  being  made  with  a  bistoury,  which  is  manageable, 
rather  than  with  a  compHcated  lancet,  which  is  not.  The 
median  cephalic  vein  crosses  the  tendon  of  the  biceps  and 
goes  to  the  outer  side  of  the  arm,  the  external  cutaneous 
nerve  lying  just  beneath  it.  The  median  basilic  is  larger, 
shows  clearer,  and  is  often  selected  for  venesection.  This 
vein  goes  to  the  inner  side,  and  lies  just  superficial  to  the 
brachial  artery,  being  separated  from  it  by  the  bicipital  fascia. 
The  internal  cutaneous  nerve  may  lie  over  or  under  it.  The 
median  cephalic  is  harder  and  safer  to  bleed  from,  as  we 
can  only  damage  a  cutaneous  nerve;  the  median  basilic  is 
easier  and  more  dangerous  to  bleed  from,  as  we  not  only 
may  damage  a  cutaneous  nerve,  but  also  the  brachial  artery 
(see  Phlebotomy,  p.  60). 

The  blood  is  allowed  to  flow  into  a  basin,  and  the  operator 
has  his  finger  on  the  pulse  to  determine  when  to  stop  the 
flow.  Bleeding  is  for  effect,  and  not  for  quantity :  the  indi- 
cation being  a  hard,  incompressible  pulse,  the  blood  should 
be  allowed  to  flow  until  the  pulse  is  soft  and  compressible. 
This  will  often  require  from  10  to  20  ounces.  Syncope  may 
occur,  and  its  onset  is  heralded  by  weakness,  dimness  of 
vision,  nausea,  vertigo,  and  sweating.  When  muscular  weak- 
ness begins  the  fillet  is  untied,  the  patient  is  placed  recumbent, 
the  arm  is  washed  with  corrosive-sublimate  solution,  a  com- 
press of  antiseptic  gauze  is  put  over  the  artery,  a  pad  of 
gauze  is  laid  over  the  compress,  and  a  roller  is  run  from 
the  hand  almost  to  the  shoulder,  the  arm  being  hung  in  a 
sling.  If  the  patient  faints,  he  is  placed  with  his  head  lower 
than  the  body;  cold  water  is  thrown  in  his  face,  mustard  is 
put  over  the  heart,  and  ammonia  is  passed  under  the  nose. 
Caution  must  be  observed  in  using  ammonia,  as  it  will  cause 
spasm  of  the  glottis  if  long  held  directly  under  the  nostrils. 

After  bleeding  the  patient  should  be  put  upon  arterial 
sedatives,  diuretics,  diaphoretics,  anodynes,  and,  if  necessary, 


INFLAMMA  TION.  63 

purgatives.  A  favorite  mixture  of  Prof  S.  D.  Gross  was  the 
antimonial  and  saline,  consisting  of  gr.  xl  of  Epsom  salts, 
gr.  -i^  oi  tartar  emetic,  3  drops  of  tincture  of  aconite,  sj 
of  sweet  spirits  of  nitre,  in  enough  ginger  syrup  and  water 
to  make  5ss ;    given  every  four  hours. 

When  a  person  has  apoplectiform  cerebral  congestion, 
he  should  be  bled,  whether  he  is  fat  or  thin ;  if  thin,  he 
should  be  bled  from  the  arm ;  if  fat,  the  arm-veins  are 
indistinct,  "and  he  should  be  bled  from  the  external  jugular, 
cutting  across,  and  not  with,  the  fibres  of  the  platysma 
myoides  muscle. 

Arterial  sedatives  are  of  great  use  before  stasis  is  pro- 
nounced ;  if  used  after  it  exists,  they  will  increase  it.  If 
stasis  exists,  relieve  it  by  bleeding  before  using  the  sedatives. 
Venesection  abolishes  stasis  and  lowers  tension,  and  arterial 
sedatives  maintain  the  effect  and  hold  the  ground  which  is 
gained.  The  arterial  sedatives  emiployed  are  aconite,  vera- 
trum  viride,  gelsemium,  and  tartar  emetic.  These  sedatives 
lessen  the  force  and  the  frequency  of  the  heart-beats,  and 
thus  slow  and  soften  the  pulse,  and  are  suited  to  a  robust 
person  with  an  acute  inflammation,  but  are  not  suited  to 
a  weak  man  in  an  adynamic  state. 

Aeonite  is  given  in  small  doses,  never  in  large  amounts. 
One  drop  of  the  tincture  in  a  little  water  is  given  every  half 
hour  until  its  effect  is  manifest  on  the  pulse,  when  it  may  be 
given  every  two  or  three  hours.  Large  doses  of  aconite 
produce  nausea  and  vomiting,  and  are  dangerous.  Aconite 
lowers  the  temperature,  slows  the  pulse,  and  produces  dia- 
phoresis. 

Veratrmn  viride  is  a  powerful  agent  to  slow  the  pulse  and 
to  lower  blood-pressure ;  it  produces  moisture  of  the  skin, 
and  often  nausea.  It  is  given  in  i-drop  doses  of  the  tinc- 
ture every  half  hour  until  its  physiological  effects  are  mani- 
fested, when  the  period  between  doses  is  extended  to  two 


64  A   MANUAL    OF  SURGERY. 

or  three  hours.  Ten  drops  of  laudanum  given  a  quarter  of 
an  hour  before  each  dose  of  aconite  or  of  veratrum  viride 
will  correct  nausea. 

Gclsciiiiuni  is  an  arterial  sedative  highly  approved  by 
Bartholow.  It  is  given  in  doses  of  10  drops  of  the  tincture 
every  three  of  four  hours. 

Tartar  emetic  lowers  arterial  tension  and  lessens  the  pulse- 
rate.  This  drug  is  not  largely  employed ;  if  it  is  used  with 
the  greatest  care  it  is  no  better  than  some  other  agents,  and 
if  it  is  not  so  used  it  will  cause  dangerous  depression.  The 
dose  is  from  gr.  ^  to  gr.  -^  in  water  every  three  hours  until 
the  physiological  effects  are  manifest. 

Cathartics. — The  tongue  affords  the  chief  indication  for 
the  use  of  cathartics.  Treatment  in  an  inflammation  can  be 
inaugurated,  if  constipation  exists,  by  giving  a  cathartic. 
Castor  oil  can  be  given  in  capsules,  or  the  juice  of  half  a 
lemon  can  be  squeezed  into  a  tumbler,  4  ounces  of  oil 
poured  in,  and  the  rest  of  the  lemon  squeezed  on  top,  thus 
making  a  not  unpalatable  mixture.  Aloin,  podophyllum, 
the  salines,  and  calomel  in  5-  or  lo-grain  doses,  followed  by 
a  saline,  have  their  advocates.  In  peritonitis  the  salines  are 
of  unquestionable  value,  a  teaspoonful  of  Epsom  salt  and 
a  teaspoonful  of  Rochelle  salt  being  given  hourly  until  a 
movement  occurs.  In  the  course  of  the  case,  from  time  to 
time,  if  there  be  constipation,  coated  tongue,  and  foul  breath, 
there  should  be  ordered  gr.  j  of  calomel  with  gr.  xxiv  of 
bicarbonate  of  sodium,  made  into  twelve  powders,  one  being 
given  every  hour ;  if  the  bowels  are  not  moved  by  the  time 
the  powders  are  all  taken,  a  saline  should  be  given.  If  a 
violent  purgative  effect  is  desired,  as  in  meningitis,  croton  oil 
or  elaterium  may  be  ordered.  If  constipation  is  persistent,  give 
fluid  extract  of  cascara  sagrada  daily  (15  to  30  drops),  or  a 
pill  at  night  containing  gr.  1  of  extract  of  belladonna,  gr.  \ 
of  extract  of  nux  vomica,  gr.  -^  of  aloin,  gr.  \  of  extract  of 


INFLAMMA  TION.  65 

physostigma,  and  gr.  ss  of  oil  of  cajuput.  Enemas  or  clysters 
may  be  used  in  some  cases,  A  very  useful  enema  is  com- 
posed of  f5J  of  oil  of  turpentine,  fsiss  of  olive  oil,  f^ss  of 
mucilage  of  acacia,  in  f  5x  of  water.  Soap-suds  and  vinegar 
in  equal  parts  make  a  serviceable  clyster.  A  combination 
of  oil  of  turpentine,  castor  oil,  the  yolk  of  an  ^g^,  and  water 
can  be  used.  Asafetida,  gr.  xxx  to  the  yolk  of  one  ^^%, 
makes  a  good  enema  to  amend  flatulence. 

Diaphoretics  are  ver\^  useful.  A  good  sweat  in  the  start 
of  a  tonsillitis  may  abort  the  disease.  Dover's  powder  is 
commonly  used,  but  pilocarpine  is  preferred  by  some. 
Camphor  in  doses  of  from  5  to  10  grains  is  diaphoretic, 
and  so  are  antimony  and  ipecac.  Acetate  and  citrate  of 
ammonium,  opium,  alcohol,  hot  drinks,  heat  to  the  surface 
(baths,  hot  bricks,  hot-water  bags),  serpentaria,  and  guaiac 
are  diaphoretic  agents. 

Diuretics  are  useful  in  fevers  when  the  urine  is  scanty  and 
high-colored,  and  are  valuable  aids  in  removing  serous  effu- 
sions and  other  exudates.  Among  the  diuretics  may  be 
mentioned  calom.el  in  repeated  doses,  cocaine,  caffeine,  alco- 
hol, digitalis,  the  nitrites,  squill,  turpentine,  copaiba,  and 
cantharides.  The  liquor  potassae  and  the  acetate  of  potas- 
sium are  the  best  agents  to  increase  the  solids  in  the  urine. 
The  liquor  potassae  citratis  in  doses  of  gr.  xxx  is  efficient. 
Large  draughts  of  water  wash  out  the  kidneys.  In  weak 
heart  the  citrate  of  caffeine  is  a  good  stimulant  diuretic. 

A?iodynes  and  hypnotics  may  be  required.  Dover's  pow- 
der, besides  being  diaphoretic,  is  anodyne.  Opium  acts  well 
after  bleeding  or  purgation.  If  it  causes  nausea,  it  should 
be  preceded  one  hour  by  gr.  xxx  of  bromide  of  potassium. 
Opium  is  used  by  the  mouth,  by  the  rectum,  or  hypodermat- 
ically.  It  is  used  when  there  is  pain,  but  its  use  is  not  to 
be  long  persisted  in  if  it  can  be  avoided.  It  is  given  in 
doses  measured  purely  by  the  necessities  of  the  case.  If 
5 


66  A   MANUAL    OF  SURGERY. 

opium  disagrees,  try  the  combination  of  morphia  with  atro- 
pine. After  an  operation  antipyrine  or  phenacetine  will  often 
quiet  pain  and  secure  sleep.  When  a  person  feels  '^  so  tired 
he  can't  sleep,"  alcohol  in  the  form  of  whiskey  or  brandy 
must  be  given.  Sleeplessness  not  due  to  pain  is  met  by 
chloral,  the  bromides,  or  sulphonal.  Chloral  is  dangerous 
in  conditions  of  weak  heart  or  exhaustion.  Bromides  must 
be  given  in  large  doses.  Sulphonal  must  be  given  about 
four  or  five  hours  before  sleep  is  expected,  in  doses  of  from 
gr.  X  to  gr.  XV  in  hot  milk. 

Antipyretics,  as  exemplified  in  diaphoretics,  purgatives, 
and  arterial  sedatives,  have  previously  been  alluded  to 
(p.  63).  There  are  two  great  classes  of  febrifuges — those 
which  lessen  heat-production  and  those  which  increase  heat- 
elimination.  In  the  first  group  we  find  quinine,  salicylic 
acid  and  the  salicylates,  kairine,  alcohol,  antimony,  aconite, 
digitalis,  cupping,  and  bleeding.  In  the  second  group  we 
find  alcohol,  nitrous  ether,  antipyrine,  antifebrine,  phenace- 
tine, opium,  ipecac,  cold  to  the  surface,  and  cold  drinks.  In 
surgical  inflammations  it  is  rarely  necessary  to  employ  heroic 
means  to  lower  temperature.  The  use  of  such  an  agent 
as  antipyrine  is  contraindicated  in  the  weak  and  adynamic, 
and  it  is  never  to  be  thought  of  as  a  means  of  lowering 
temperature  unless  the  latter  goes  above  103°.  A  good  plan 
when  compelled  to  use  antipyretics  is  to  start  the  reduction  of 
temperature  with  antipyrine  and  to  keep  it  down  with  gr.  xx 
of  quinine.  Quinine,  in  doses  of  gr.  xx  to  gr.  xxx  given  at 
4  p.  M.,  may  prevent  an  evening  rise ;  salol  or  salicin  can  be 
given  during  the  day.  Inunctions  of  30  minims  of  guaiacol 
lower  the  temperature  in  tubercular  conditions  and  in  septic 
fevers.  These  inunctions  are  made  upon  the  abdomen,  and 
often  produce  surprising  results. 

Emetics. — An  emetic  does  good  when  there  are  a  parched, 
coated   tongue,   a   dry  and    hot    skin,   nausea,  and  gastric 


IX FLA  MMA  TION.  6/ 

oppression.  There  can  be  used  oj  of  alum  in  molasses, 
gr.  XX  of  sulphate  of  zinc,  or  a  tablespoonful  of  mustard 
and  a  teaspoonful  of  salt  giv^en  in  warm  water,  followed  by- 
large  draughts  of  warm  water.  Ipecac  in  a  dose  of  gr.  xx 
can  be  employed.  The  emetic  dose  of  tartar  emetic  is  gr.  ij, 
but  it  is  too  depressant.  The  sulphuret  of  antimony  in 
doses  of  from  i  to  5  grains  is  safe.  Apomorphia  hypoder- 
matically,  in  a  dose  of  from  gr.  ^  to  gr.  \,  will  act  in  five 
minutes.  Emetics  are  valuable  in  inflammatory  conditions 
of  the  air-passages.  Emetics  are  contraindicated  in  diseases 
of  the  heart,  brain,  and  bowels,  in  hernia,  in  dislocations,  in 
fractures,  and  in  aneurysms. 

Mercury  and  the  Iodides. — Mercur)'  is  an  alterative — that 
is,  an  agent  which  favorably  affects  body-nutrition  without 
causing  any  recognizable  change  in  the  fluids  or  the  solids 
of  the  body.  Mercury  lessens  blood-plasticity,  hinders  the 
exudation  of  liquor  sanguinis — thus  furnishing  less  food  to 
the  cells  in  the  perivascular  tissues — and  retards  the  for- 
mation of  embryonic  tissue.  Further,  by  a  stimulant  action 
on  the  absorbents  it  promotes  the  breaking  up  of  an  exist- 
ing inflammatory  exudate,  and  hence  limits  damage  from 
excess  of  embryonic  tissue.  The  time  at  which  mercury 
is  best  given  is  when  violent  symptoms  have  abated,  the 
guide  being  reduced  temperature  and  moist  skin.  It  is  often 
given  in  conjunction  with  sorbefacients  (as  the  acetate  of 
lead),  and  is,  when  possible,  associated  with  compression. 
It  is  usually  given  until  the  gums  are  slightly  touched,  but 
is  not  often  given  to  salivation.  When  the  breath  becomes 
offensive  and  the  gums  tender  on  snapping  the  teeth,  the 
dose  should  be  reduced.  In  iritis  mercury  is  used  to  get 
rid  of  the  plastic  effusion  which  is  causing  pupillary  fixation 
and  opacity.  In  keratitis  the  gums  should  be  touched 
lightly.  In  orchitis,  after  the  subsidence  of  the  acute  symp- 
toms, mercury  should  be  employed.     In  pericarditis,  menin- 


68  A   MANUAL    OF  SURGERY. 

gitis,  peritonitis,  and  in  many  chronic  and  lingering,  and  in 
all  syphilitic,  inflammations  this  drug  may  be  used. 

Some  persons  will  be  salivated  with  very  minute  doses 
of  mercury,  either  from  idiosyncrasy  or  previous  saturation. 
Others  can  take  enormous  doses  without  any  appreciable 
constitutional  effect,  but  its  action  can  be  favored  by  a  com- 
bination with  ipecac  or  with  tartar  emetic. 

Salivation,  ptyalisni,  or  mcrairial  stomatitis  is  made  mani- 
fest by  the  excessive  flow  of  saliva ;  white  patches  over  the 
buccal  surface  ;  purple,  tender,  spongy,  ulcerating  gums  ;  foul 
breath  ;  gray-coated  tongue  ;  tenderness,  loosening,  and  later 
dropping  out,  of  the  teeth  ;  enormous  swelling  of  the  tongue, 
jaws,  face,  the  salivary  and  lymphatic  glands ;  and  great 
interference  with  audition,  respiration,  articulation,  and  deglu- 
tition. Gangrene  may  occur.  Salivation  is  to  be  treated  by 
astringent  gargles,  atropine,  chlorate  of  potassium  internally 
and  locally,  anodynes,  and  iodide  of  potassium.  If  suffoca- 
tion is  impending,  scarify  the  tongue.  A  very  useful  mouth- 
wash is  prepared  as  follows : 


-M. 


A  favorite  prescription  with  the  late  Professor  Gross  con- 
sisted of  3j  of  liquor  plumbi  subacetatis  (Goulard's  extract) 
to  5viij  of  water,  used  as  a  mouth-wash  every  hour.  The 
dental  discoloration  produced  by  Goulard's  extract  will  after 
a  time  pass  away.  A  very  useful  gargle  consists  of  gr.  xlviij 
of  chlorate  of  potash,  3ss  of  tincture  of  myrrh,  and  sufficient 
elixir  of  calisaya  to  make  fsiij.  This  can  be  given  in  sj 
doses  every  three  or  four  hours,  or  be  used  as  a  mouth- wash. 
The  usual  plan  of  treatment  for  salivation  is  to  stop  the 
mercury ;  place  on  a  bland  diet ;  if  the  swelling  or  pain 
interferes  with  feeding,  push  into  the  pharynx  through  the 


R.  Acid,  boracic, 

.•^ij; 

Listerine, 

Jiv; 

Aqu?e, 

q.  s.  ad  f^viij 

Sig.  Locally  p.  r.  n. 

INFLAMMA  TION.  69 

nose  a  tube,  and  feed  through  it ;  after  taking  food  clean  out 
thoroughly  and  swab  the  mouth  every  two  or  three  hours 
with  a  cotton  pledget  saturated  with  peroxide  of  hydrogen, 
and  follow  this  by  the  use  of  one  of  the  above-named  mouth- 
washes. A  hot  bath  should  be  ordered  once  a  day,  or  a 
Turkish  bath  every  third  day.  Give  10  grains  of  iodide  of 
potassium  three  times  a  day,  and  gr.  jo^o"  ^^  atropine  at 
night.  Sleep  is  secured  by  opiates  if  the  pain  is  severe. 
Stimulants  are  indicated  for  exhaustion.  When  convalescence 
begins  there  should  be  ordered  open-air  exercise,  nourishing 
food,  red  wines  or  malt  liquors,  and  tonics.  A  mild  case  of 
salivation  can  be  arrested  in  two  or  three  days  ;  a  severe  case 
is  of  uncertain  duration,  and  may  prove  fatal. 

In  giving  mercur}',  if  a  prompt  effect  is  desired,  give  gr.  iij 
of  calomel  every  three  hours  until  a  metallic  taste  is  noted 
in  the  mouth.  If  the  case  is  not  so  urgent,  gray  powder  is 
a  good  combination.  If  it  is  desired  to  give  the  drug  for 
some  time,  corrosive  sublimate  is  a  suitable  form,  and  small 
doses  will  actually  increase  the  number  of  red  blood-cor- 
puscles. Corrosive  sublimate  is  to  be  given  alone  or  com.- 
bined  only  with  iodide  of  potassium.  In  the  prolonged  use 
of  mercury  it  will  often  be  necessary  to  give  at  the  same  time 
a  little  opium  to  prevent  diarrhoea  and  griping.  A  rapid 
effect  can  be  obtained  by  rubbing  with  a  gloved  hand  5j  of 
the  oleate  of  mercury  or  .^ss  of  the  ointment  into  the  groin, 
the  axillae,  or  the  inside  of  the  thighs.  Suppositories  of  mer- 
curial ointment  induce  rapid  ptyalism.  Hypodermic  injec- 
tions of  corrosive  sublimate  can  be  used,  and  must  be  thrown 
deeply  into  the  muscles  of  the  buttock.  Old  people,  those 
who  are  exhausted,  anaemic,  and  broken  down,  and  the  scrof- 
ulous, bear  mercury  badly.  If  it  be  given  at  all,  it  must  only 
be  given  to  them  in  small  amounts  and  for  a  brief  time. 

Alkaline  iodides,  which  are  useful  in  remo\'ing  the  prod- 
ucts of  inflammation,  can  be  given   for  a   long   time,   and 


70  ^   MANUAL    OF  SURGERY. 

they  admirably  supplement  mercurials.  Iodide  of  potassium 
can  be  prescribed  in  combination  with  corrosive  sublimate, 
as  follows : 

K.   Ilydrarg.  chlor.  conos.,  gf- U  ; 

Potass,  iodidi,  ^v  et  ^j ; 

Syr.  sarsaparillae  comp.,  q.  s.  ad  f5viij. — M. 
Sig.  fjij,  in  water,  after  meals. 

Iodide,  well  diluted,  is  given  on  a  full  stomach  ;  it  is  never 
given  concentrated  nor  before  meals.  A  convenient  mode 
of  administration  is  to  procure  a  concentrated  solution  of 
the  iodide  of  potassium,  remembering  that  every  drop  equals 
gr.  j  of  the  drug,  and  give  as  many  drops  as  desired  in  half 
a  glass  of  water  after  meals.  If  this  disagrees,  add  to  each 
dose,  after  it  is  put  in  water,  3j  of  the  aromatic  spirits  of 
ammonia.  Extract  of  licorice  is  a  good  vehicle  for  iodide. 
If  the  mixture  in  water  disagrees,  it  should  be  tried  in  milk. 
Capsules  are  satisfactory,  but  a  drink  of  water  should  be 
taken  just  before  and  again  just  after  taking  a  capsule,  to 
protect  the  stomach  from  the  concentrated  drug.  Iodide  of 
sodium  may  agree  when  iodide  of  potassium  does  not. 
When  the  iodides  disagree  they  produce  iodism.  The  first 
indications  of  iodism  are  a  bad  taste  in  the  mouth,  running 
of  the  eyes  and  nose,  and  sneezing,  followed  by  a  feeling 
of  exhaustion,  absolute  loss  of  appetite,  nausea,  tremor,  and 
skin-eruptions  (acne,  hemorrhages,  blebs,  hydroa,  etc.)  If 
iodism  occurs,  stop  the  drug  and  give  the  patient  Fowler's 
solution  in  increasing  doses,  laxatives,  diuretic  waters,  and 
also  good  food  and  stimulants  if  depression  is  great.  Some- 
times belladonna  does  good  in  obstinate  cutaneous  disorders. 

AlcoJiolic  stimulants  are  used  for  conditions,  and  not  for 
diseases,  their  use  being  indicated  by  the  state  of  the  patient, 
rather  than  by  the  name  of  the  malady.  For  a  brief  acute 
inflammation  in  a  robust  young  person  alcohol  is  not 
needed ;  but  all  who   are  weak  or  exhausted — the  young. 


INFLAMMA  TIO.V  7 1 

the  old,  those  accustomed  to  alcoholic  beverages,  those  who 
have  high  temperatures  or  failure  of  circulation,  and  those 
who  labor  under  septic  inflammations  or  adynamic  pro- 
cesses— require  alcohol  to  be  given  with  a  free  hand.  Certain 
indications  for  alcohol  in  an  acute  malady  are  a  feeble,  com- 
pressible, rapid,  and  often  irregular  pulse  and  great  weakness 
of  the  first  sound  of  the  heart.  Low  muttering  delirium  is 
a  strong  indication.  There  is  no  dose  of  alcohol  in  these 
states  :  it  is  given  for  its  effect.  Two  ounces  may  be  needed 
in  a  day,  or  perhaps  twenty  ounces.  If  the  breath  of  the 
patient  smells  strongly  of  the  alcohol,  he  is  getting  too 
much.  If  delirium  increases  after  each  dose,  it  is  doing  harm. 
Alcohol  is  contraindicated  in  acute  meningitis.  In  acute  ill- 
ness use  whiskey,  brandy,  champagne,  or  alcohol  and  water. 
During  convalescence  there  may  be  used  a  little  spirit — port, 
claret,  or  sherry  wine  or  malt  liquor.  These  agents  will 
promote  appetite,  digestion,  and  sleep. 

Tonics  are  indicated  during  convalescence  from  acute  and 
throughout  the  course  of  chronic  inflammations.  There  may 
be  used  iron,  quinine,  and  strychnine  in  the  form  of  elixir; 
iron  alone,  as  in  the  tincture  of  the  chloride  ;  quinine  in  tonic 
doses  (gr.  vj  to  gr.  viij  daily) ;  or  Fowler's  solution  of 
arsenic.     An  excellent  pill  consists  of — 

R  .   Acid,  arsenos,  gr.  j ; 

Strychnini,  gr.  ss ; 

Quinine,  gr.  xlviij ; 

Ferri  redact.,  gr.  vj. 
Ft.  in  pil.  No.  xxiv. 
Sig.  One  after  each  meal. 

Bitter  tonics  before  meals  improve  the  appetite.  One  of  the 
best  of  these  tonics  is  tincture  of  nux  vomica. 

Antiplilogistic  regimen  includes  all  the  facts  relating  to 
diet,  ventilation,  cleanliness,  etc. 

Diet. — When,  in  the  early  stages  of  an  acute  inflammation, 


J 2  A    MANUAL    OF  SURGERY. 

the  patient  cannot  cat,  there  must  be  administered  a  cathartic 
before  food  is  given.  Nausea  is  combated  with  calomel  and 
soda,  drop-doses  of  a  6  per  cent,  solution  of  cocaine,  iced 
champagne,  or  cracked  ice.  When  the  process  is  depressive 
from  the  start,  and  in  any  case  after  the  earliest  stage,  feed- 
ing is  of  vital  moment.  The  great  tissue-waste  calls  for 
much  food,  but  the  impaired  digestion  demands  that  it  shall 
easily  be  assimilable;  hence  it  is  taken  in  liquid  form,  small 
quantities  being  frequently  given.  Milk  contains  all  the 
elements  required  by  the  body,  and  is  the  food  of  foods. 
If  it  disagrees,  it  should  be  boiled  and  mixed  with  lime- 
water,  or  to  each  dose  an  equal  amount  of  Vichy  or  soda- 
water  may  be  added.  Peptonized  milk  is  a  valuable  agent. 
One  part  of  milk,  2  parts  of  cream,  and  2  parts  of  lime-water 
make  a  nutritious  and  digestible  mixture.  Milk  punch  is 
largely  used.  Whey  may  be  used  when  milk  cannot  be  taken. 
Eggs  are  highly  nutritious,  but  are  apt  to  disturb  the  stom- 
ach ;  they  may  be  given  as  egg-nog,  or  simply  soft-boiled, 
or  the  yolk  can  be  beaten  up  in  a  cup  of  tea.  When  con- 
siderable nausea  exists  the  yolk  of  an  ^^^  may  be  added 
to  5j  of  lemon-juice  and  3ij  of  sugar,  the  glass  being  filled 
with  carbonated  water.  Beef  tea  is  certainly  a  stimulant, 
but  its  food-powers  are  questionable.  It  is  prepared  by  cut- 
ting up  one  pound  of  lean  beef,  adding  to  it  a  quart  of  water, 
and  then  simmering,  but  not  boiling,  down  to  a  pint,  and 
finally  by  filtering  and  skimming  the  liquid.  The  dose  is  a 
wineglassful  seasoned  to  taste.  Meat-juice,  made  by  squeezing 
out  partly-cooked  meat  with  a  lemon-squeezer,  is  also  highly 
nutritious.  Liquid-beef  peptonoids  are  both  agreeable  and 
nutritious  ;  they  are  given  in  doses  of  5ss  to  5j.  When  noth- 
ing else  will  stay  on  the  stomach  koumiss  will  often  be 
retained.  This  fermented  milk  is  nutritious,  stimulant,  and 
veiy  useful.  Coffee  is  a  valuable  stimulant  in  febrile  condi- 
tions.    When  the  sufferer  feels  able  to  eat  a  little,  any  good 


REPAIR.  .73 

soup,  Strained  and  skimmed,  should  be  ordered.  As  the 
patient  gets  better  he  may  be  fed  on  sweetbreads,  chops,  etc. 
until  he  gradually  reaches  the  ordinary  diet ;  if  his  stomach 
rejects  everything,  he  must  be  fed  by  the  rectum. 

Ventilation  and  Cleanliness. — The  ventilation  of  the  apart- 
ment is  of  the  greatest  importance.  Every  day  the  windows 
should  be  opened  widely  for  a  time,  the  patient  of  course 
being  protected.  A  constant  access  of  fresh  air  must  be 
secured,  and  the  temperature  kept  at  about  68°.  The  sick 
man  must  be  cleaned  and  be  sponged  off  with  alcohol  and 
water  every  day  if  high  fever  exists.  It  is  important  that 
the  bed-clothing  be  clean  and  that  the  sheet  be  unwrinkled, 
as  otherwise  bed-sores  may  form. 


III.    REPAIR. 

Repair  is  an  active  process  by  which  destroyed  tissues 
are  replaced,  and  it  is  due  to  increased  nutritive  activity, 
rather  than  to  inflammation.  Inflammation  may  occur,  or  w^ 
may  be  obliged  to  induce  it  when  the  blood-supply  is  scanty 
or  the  exudation  deficient;  but  certain  it  is  that  an  aseptic 
wound  heals  without  many  of  the  evidences  of  inflammation. 

Healing-  by  First  Intention. — A  wound  may  heal  by  "first 
intention."  This  mode  of  healing,  which  is  known  as  "primary 
union,"  occurs  without  suppuration.  If  pus  forms,  primary 
union  will  not  take  place.  When  the  edges  of  an  incised  wound 
are  brought  niceh'in  apposition,  after  stopping  the  hemorrhage 
and  asepticizing  thoroughly,  slight  swelling  comes  on.  but 
no  discoloration.  L}'mph  and  leucocytes  are  exuded  from 
the  vessels,  fibrin  forms  in  this  lymph,  and  the  edges  of  the 
wound  are  stuck  together  by  a  natural  cement.  In  exten- 
sive wounds  the  exudation  is  in  excess,  and  much  of  it  must 
be  drained  away,  for  its  retention  means  tension,  inflamma- 
tion, and  a  v\'arm  nest  for  pus  cocci.     The  exudation  is  con- 


74 


A    MANUAL    OF  SURGERY. 


verted  into  embryonic  tissue  by  multiplication  of  its  own 
cells  and  multiplication  of  tissue-cells.  Embryonic  or  gran- 
ulation-tissue consists  of  small  round  or  oval  cells  held 
tofTcther  by  a  jelly-like  intercellular  substance.  In  a  few 
days  some  spindle-shaped  cells  can  be  found,  and  also  large 
cells  with  one  or  more  nuclei  (epithelioid  cells).  Prolonga- 
tions of  embryonic  tissue  are  raised  up  by  capillary  loops, 
which  prolongations  fuse  with  one  another  end  to  end,  or 
they  fuse  with  other  capillary  loops,  and  are  hollowed  out 
and  become  endothelial  tubes  or  capillaries.  After  vascu- 
larization or  organization  the  embryonic  tissue  becomes 
fibrous  (Figs.  21,  22).    The  final  step  in  healing  is  the  cover- 


'y 


Fig.  21. — Nuclei  developing  into 
Fibres  (Bennett). 


Fig.  22. — Cells  developing  into  Fibres 
(Bennett). 


ing  of  the  surface  with  epithelium,  the  cells  springing  from 
the  epithelial  cells  upon  the  edges.  This  final  process  is 
called  "  cicatrization,"  and  consists  in  the  contraction  of  the 
wound  and  its  skinning  over.  The  "  immediate  union  "  of 
some  writers  never  occurs.  It  means  the  union  of  micro- 
scopical parts  to  their  counterparts  without  an\'  effort  at 
repair.  A  first  union  is  effected  always  by  fibrin,  and  next 
by  embr\'onic   tissue. 

Healing  by  Second  Intention. — In  a  wound  whose  edges 
cannot  be  approximated  a  great  gap  has  to  be  filled,  which  is 
accomplished  by  granulation.  This  process  is  known  as  "  heal- 


REPAIR.  75 

ing  by  granulation"  or  "second  intention."  In  an  hour  or  so 
after  the  infliction  of  such  a  wound  (it  may  be  in  less  time)  the 
raw  surface  is  covered  with  a  thin  glazed  layer  of  coagulated 
exudate.  This  glaze  is  fibrin,  which  soon  becomes  filled  with 
leucocytes  ;  underneath  this  fibrin-coat  proliferation  is  pro- 
ceeding and  embryonic  tissue  is  forming.  The  wound-dis- 
charge is  at  first  thin  and  red,  but  in  a  few  days  becomes 
purulent  and  so  profuse  as  to  wash  away  the  discolored  fibrin- 
coat.  Granulations  are  now  disclosed,  the  embryonic  tissue 
being  lifted  up  in  countless  points  by  capillary  loops.  When 
these  loops  approach  the  surface  contraction  begins,  which 
brings  the  edges  of  the  wound  nearer  together  and  gradually 
cuts  off  the  excessive  blood-supply  which  is  no  longer  needed. 
When  the  granulations  reach  the  surface,  epithelium  in  a  thin 
bluish  film  grows  from  the  epithelial  cells  at  the  edge  and 
covers  the  ulcer.  Cicatrization  is  contraction  plus  skinning 
over  with  epithelium.  Epithelium  can  only  spring  from 
the  wound-edges,  unless  there  be  some  epithelial  structural 
remains  in  the  wound,  such  as  an  undestroyed  papilla,  a 
sweat-duct,  or  a  hair-follicle.  If  the  granulations  rise  above 
the  surface,  constituting  exuberant  granulations  or  proud 
flesh,  they  must  be  cut  off  or  burned  away  before  epithelium 
will  grow  over  the  wound.  Pale  oedematous  granulations 
are  usual  in  tuberculous  processes.  The  contraction  of 
cicatrization  results  from  the  conversion  of  embryonic  tissue 
into  fibrous  tissue  (Figs.  21,  22).  Contraction  is  so  great 
after  some  wounds  as  to  cause  terrible  deformities.  This  is 
notably  the  case  after  burns  whose  scars  or  cicatrices  con- 
tain much  elastic  tissue.  Coagulation  necrosis  of  a  super- 
ficial la}'er  of  granulation-tissue  produces  a  diphtheritic 
membrane  or  aplastic  lymph.  This  coagulation  necrosis 
depends  on  capillary  closure  or  lack  of  capillary  develop- 
ment, the  embryonic  tissue  dying  for  want  of  nutriment. 
Healing  by  Third  Intention. — This  consists  in  the  union 


76  A   MANUAL    OF  SURGERY. 

of  two  granulating  surfaces,  as  the  union  of  collapsed  abscess- 
walls.  In  subcutaneous  wounds,  if  aseptic,  healing  occurs 
without  suppuration.  First  a  blood-clot  fills  the  wound, 
exudate  occurs,  and  embryonic  tissue  forms  in  the  walls  of 
the  cavity ;  the  new  granulation-tissue  grows  into  the  clot, 
which  is  broken  up  and  absorbed,  and  organization  and  con- 
traction of  the  embryonic  tissue  take  place.  If  suppuration 
occurs,  an  abscess  forms.  Healing  under  an  aseptic  blood- 
clot  is  healing  "  by  first  intention."  The  fibrous  tissue  of  a 
scar  arises  from  connective  tissue,  which  itself  arose  from 
embryonic  tissue.  The  multiplication  of  connective -tissue 
cells  may  be  by  direct,  but  it  is  usually  by  indirect,  division. 

Cell-Division. — Direct  cell-division  consists  in  division  of 
the  nucleus  followed  by  division  of  the  entire  cell. 

Indirect  cell-division^  or  karyokinesis,  shows  remarkable 
chancres  in  the  nucleus.  The  membrane  of  the  nucleus  dis- 
appears ;  the  nuclear  network  becomes  first  close  and  then 
more  open,  and  the  cells  become  round,  if  not  so  before. 
The  network  of  the  nucleus,  now  consisting  of  one  long 
fibre,  takes  the  shape  of  a  rosette ;  next  it  takes  a  star- 
form — the  aster  stage  ;  two  sets  of  V's  next  form — the  equa- 
torial stage ;  an  equatorial  line  appears  and  widens,  and  each 
set  of  V's  retreats  toward  a  pole.  Thus  two  new  nuclei  are 
formed,  each  polar  V  passing  in  inverse  order  through  the 
previous  changes  of  shape,  and  the  protoplasm  of  the  original 
cell  collects  about  each  nucleus  (Fig.  23). 

In  non-vascular  tissues,  such  as  cornea  or  cartilage,  the 
wound  is  glued  together  by  fibrin,  the  exudate  having  come 
along  the  lymph-spaces  from  adjacent  vascular  areas.  Organ- 
ization occurs  by  multiplication  of  fixed  tissue-cells  and 
leucocytes.  Divided  muscle  unites  by  fibrous  tissue.  Divided 
nerve,  when  approximated,  can  regenerate.  Tendon  unites 
by  fibrous  tissue  which  after  a  time  becomes  truly  tendinous. 
Bone  first  unites  by  embryonic  tissue  which  becomes  fibrous 


SURGICAL   FEVERS. 


77 


and  bony.  When  an  artery  is  ligated,  embryonic  tissue  forms 
in  and  around  it,  the  walls  soften  and  are  converted  into  the 
same  tissue,  and  the  artery  is  organized  into  a  fibrous  cord. 


Fig.  23.— Forms  Assumed  by  a  Nucleus  Dividing  (Green,  from  Flemming). 

An  ulcer  heals  in  the  same  manner  as  does  a  wound — by 
second  intention.  An  abscess  heals  by  collapse  of  its  sides 
and  their  adhesion.  The  sides  are  embryonic  tissue  which 
is  formed  into  granulations,  these  granulations  unite,  and 
organization  into  fibrous  tissue  takes  place. 


IV.    SURGICAL  FEVERS. 

The  surgeon  encounters  fever  as  a  result  of  an  inflamma- 
tion or  an  aseptic  wound,  in  consequence  of  infection,  and 
in  certain  maladies  of  the  nervous  system.  It  is  important 
to  remember  that,  while  elevated  temperature  is  generally 
taken  as  a  gauge  of  the  intensity  of  fever,  it  is  not  a  certain 
index.  There  may  be  fever  with  subnormal  temperature  (as 
in  the  collapse  of  typhoid  or  pneumonia),  and  there  may  be 
elevated  temperature  without  true  fever  (as  in  certain  brain 
diseases).  It  is  true,  however,  that  elevation  of  temperature 
is  almost  always  noted. 


78  A   MANUAL    OF  SC/RGEKV. 

Tlic  essential  pJienomena  of  fever,  according  to  Maclagan, 
arc — (i)  wasting  of  nitrogenous  tissue;  (2)  increased  con- 
sumption of  water;  (3)  increased  elimination  of  urea;  (4) 
increased  rapidity  of  circulation;  and  (5)  preternatural  heat. 

Types  of  Fever. — Fevers,  whatever  their  causation  and 
special  names,  belong  to  one  of  three  fundamental  types, 
just  as  the  diverse  varieties  of  men  belong  to  certain  funda- 
mental races.  These  three  types  are — (l)  sthenic  fever  ;  (2) 
asthenic  fever ;  and  (3)  nervous  fever. 

Sthenic  Fever. — The  sthenic  or  inflanmiatory  t}'pe,  found 
in  the  young  and  robust  as  a  result  of  acute  inflammation, 
is  characterized  by  violent  action  at  an  early  period.  It  is 
ushered  in  by  malaise,  chilly  sensations  or  a  moderate  chill, 
want  of  appetite,  nausea  and  often  vomiting,  and  pain  in  the 
back  and  limbs.  The  pulse  shows  increased  pressure,  is  fre- 
quent, full,  hard,  and  incompressible  (runs  from  90  to  120); 
the  face  is  flushed;  the  eyes  are  suffused  and  intolerant  of 
light;  the  skin  is  dry;  the  respiration  is  accelerated;  the 
mouth  is  dry,  and  the  tongue  is  coated.  There  is  thirst, 
anorexia,  often  nausea  and  bilious  vomiting,  and  constipation  ; 
headache ;  an  insufficient  amount  of  sleep,  and  disturbing 
dreams  when  the  patient  sleeps;  he  may  show  a  delirium 
of  an  agreeable  character.  There  is  aching  and  soreness 
in  the  back  and  limbs,  and  emaciation.  The  temperature, 
which  attains  its  height  in  from  two  to  four  days,  rarely 
exceeds  103°.  The  urine  is  scanty,  high-colored,  offensive, 
and  often  contains  albumin  and  casts.  A  fever  may  be 
sthenic  in  the  beginning,  but  become  asthenic  later  in  the 
attack.  The  genuine  sthenic  type  terminates  by  lysis.  An 
acute  pleuritis  in  a  robust  subject  affords  an  example  of  the 
sthenic  type  of  fever. 

Asthenic  Fever. — The  asthenic  typhoid  or  adynamic  type 
occurs  in  the  weak,  the  sickly,  the  debilitated,  and  in  those 
■at   the    extremes  of  life.     It  is  the  fever  of  pyaemia,  sep- 


SURGICAL   FEVERS.  79 

ticaemia,  diphtheria,  typhoid,  etc.,  and  it  is  often  ushered  in 
by  a  chill  or  chills  and  profound  depression.  The  pulse  is 
soft,  tremulous,  weak,  compressible,  frequent,  and  quick  (no 
to  160).  The  temperature  is  elevated  (100°  to  108°),  often  for 
long  periods,  and  oscillates  greatly.  Chills  may  recur;  the 
respirations  are  rapid  and  shallow  ;  the  skin  is  cold,  clammy, 
often  drenched  with  cold  sweat ;  the  face  is  lividly  pale ;  the 
eyes  sunken  and  partly  closed  ;  the  tongue  is  dry,  hard,  and 
covered  with  a  brown  fur ;  sordes  gather  on  the  gums  and 
teeth ;  the  muscles  and  tendons  twitch  {subsultus  tendimtui) ; 
the  patient  picks  at  the  bed-covers  in  a  bad  case  {carphalogid) ; 
the  appetite  is  absent,  and  the  powers  of  assimilation  at  a 
low  ebb ;  there  are  hiccough,  great  wasting,  and  diarrhoea ; 
the  urine  is  scanty,  high-colored,  often  albuminous ;  the 
mental  condition  is  one  of  torpor,  apathy,  or  stupor,  with 
low  muttering  delirium.  Bad  subsultus,  persistent  vomiting, 
carphalogia,  or  continued  hiccough  and  a  "  Hippocratic " 
countenance  usually  indicate  death,  which  is  apt  to  happen 
in  coma.  The  Hippocratic  countenance  presents  the  follow- 
ing elements  :  "A  sharp  nose,  hollow  eyes,  collapsed  temples; 
the  ears  are  cold,  contracted,  and  their  lobes  turned  out;  the 
skin  about  the  forehead  is  rough,  distended,  and  parched, 
the  color  of  the  whole  face  being  brown,  black,  livid,  or 
lead  colored." 

Nervous  Fever, — The  irritative  or  nervous  type  is  apt  to 
attend  the  adynamic  type,  and  is  often  met  with  following 
carbuncles,  sloughing,  and  late  eruptions  of  pox.  The  tem- 
perature is  irregularly  elevated  (iOl°  to  103°).  There  are 
nervous  chills,  but  not  rigors.  The  mind  is  fretful,  peevish, 
anxious,  and  despondent ;  pain  is  magnified ;  the  pulse  is 
quick,  small,  jerking,  and  often  irregular ;  the  skin  is  hot 
and  dry ;  severe  headache  and  pain  in  the  back  and  limbs 
are  complained  of;  insomnia  is  distressing,  and  the  sleep 
obtained  is  disturbed  by  vivid  dreams ;  restlessness  is  pro- 


8o  A   MANUAL    OF  SURGERY. 

nounced,  and   loud   noises   or  bright   lights  produce   much 

annoyance. 

Traumatic  fevers  follow  a  traumatism  and  attend  the  heal- 
ing of  a  wound.  The  forms  are — (i)  primary  wound-fever; 
and  (2)  secondary  wound-fever. 

Pi'iniary  ivoiind-fcvcr  is  a  result  of  the  changes  going  on 
in  a  wound  which  does  not  contain  pus.  It  is  divided  into 
two  forms  :  (cil)  aseptic  fever ;  and  {b)  traumatic  or  surgical 
fever. 

Aseptic  fcvcv  appears  after  a  thoroughly  aseptic  operation 
and  after  a  simple  fracture  or  a  contusion.  It  may  appear 
during  the  evening  of  the  operation  or  not  until  the  next 
day,  and  reaches  its  highest  point  by  the  evening  of  the 
second  day  (100°  to  102°).  This  elevation  is  spoken  of  as 
the  **  post-operation  rise."  Besides  the  fever  there  are  no 
obvious  symptoms ;  the  patient  feels  first-rate,  and  often 
wants  to  sit  up  ;  there  are  no  rigors  and  there  is  no  delirium. 
This  fever  is  due  to  absorption  of  pyrogenous  material  from 
the  wound-area,  where  clot-tissue  and  exudate  may  be  ab- 
sorbed. The  pyrogenous  element  seems  to  be  fibrin-ferment 
In  some  cases  an  aseptic  fever  may  appear  after  an  opera- 
tion, and  later  be  replaced  by  a  septic  fever.  If  the  tem- 
perature remains  high  after  a  few  days  or  if  other  symp- 
toms appear,  the  wound  should  be  examined  at  once,  as 
trouble  certainly  exists. 

Traiunatic  or  surgical  fever  is  seen  in  the  healing  of  in- 
fected wounds  where  there  is  inflammation,  but  no  pus. 
This  fever  is  due  to  the  presence  of  bacteria  in  the  wound 
and  the  absorption  of  their  ptomaines.  It  ceases  as  soon  as 
free  discharge  occurs,  and  its  appearance  is  an  indication  for 
instant  drainage.  The  temperature  rises  pretty  sharply  in  a 
day  or  so  after  the  operation,  ascends  with  evening  exacer- 
bations and  morning  remissions,  and  reaches  its  height  about 
the  third  or  fourth  day,  when  suppuration  sets  in ;  the  tern- 


TERMIXATIOXS   OF  IXFLAMMATION.  8 1 

perature  begins  to  drop  if  the  pus  has  free  exit,  and  reaches 
normal  at  the  end  of  a  week  (see  Suppurative  Fever).  When 
the  fever  begins  the  wound  should  be  inspected,  the  stitches 
removed  where  stitch-abscesses  exist,  and  the  area  drained 
and  asepticized.  The  fact  that  this  fever  is  apt  to  cease 
when  suppuration  begins  led  the  older  surgeons  to  hope  for 
pus  and  to  endeavor  to  cause  it  to  form. 

Secondary  Wound-fever :  Suppurative  Fever. — This  fever, 
which  is  due  to  the  absorption  of  the  ptomaines  of  pyogenic 
cocci,  occurs  after  suppuration  has  begun,  and  is  found  when 
the  pus  has  not  free  exit.  If  the  post-operation  rise  con- 
tinues, or  if,  after  it  has  gone,  a  secondary  rise  occurs,  look 
out  for  pus.  Suppuration  in  a  wound  is  indicated  by  a  rapid 
rise  of  temperature — possibly  first  by  a  chill.  The  wound 
must  at  once  be  drained.  In  a  chronic  suppuration,  such  as 
occurs  in  a  tubercular  process,  there  exists  a  fever  with  marked 
morning  remissions  and  vesperal  exacerbations,  attended 
with  night-sweats,  emaciation,  diarrhoea,  and  exhaustion. 
This  is  known  as  "  hectic  fever;"  it  is  really  a  chronic  sup- 
purative fever.  The  treatment  of  hectic  fever  consists  in 
draining  or,  if  possible,  excising  the  infected  area,  a  nutri- 
tious diet,  open  air,  stimulants,  tonics,  and  in  giving  remedies 
for  the  exhausting  sweats. 


V.   TERMINATIONS  OF  INFLAMMATION. 

Inflammation  can  terminate  in — (l)  effusion  of  serum; 
(2)  effusion  of  lymph;  (3)  formation  of  pus;  (4)  ulceration; 
and  (5)  mortification. 

Effusion  of  Serum. — The  so-called  "  serum  "  of  inflamma- 
tion is  not  serum  at  all,  but  is  liquor  sanguinis.  We  meet 
with  true  serum  in  passive  congestions,  but  not  in  active 
hyperaemias.  Effusion  of  serum  into  connective  tissue  con- 
stitutes oedema ;  and  into  a  sac,  like  the  peritoneum,  dropsy ; 

6 


82  A   MANUAL    OF  SURGERY. 

dropsy  being  designated  by  the  prefix  hydro-,  as  hydrothorax. 
Abdominal  dropsy  is  ascites.  Anasarca  is  general  effusion 
of  serum  resulting  from  altered  blood-pressure.  CEdema  is 
made  manifest  by  the  signs  of  inflammation,  the  swelling 
being  soft,  smooth,  and  inelastic,  and  the  parts  pitting  on 
pressure.  Effusion  of  serum  may  be  beneficial,  unloading 
the  vessels  and  hence  relieving  pain,  tension,  and  hypersemia. 
It  can  do  harm.  In  connective  tissue  it  may  exist  in  such 
quantity  as  to  cut  off  the  circulation  of  certain  areas,  thus 
causing  necrosis.  Effusion  into  a  cavity  causes  pressure  on 
its  contained  parts;  for  instance,  in  a  hydrothorax  the  lung 
is  compressed. 

Treat inc lit. — CEdema  can  be  relieved  by  multiple  punc- 
tures, but  if  it  threatens  necrpsis  free  incisions  must  be 
made.  If  the  dropsy  be  considerable,  the  fluid  must  be  let 
out  by  tapping,  aspiration,  or  incision.  Tapping  must  be 
done  aseptically,  but  it  offers  danger  of  infection,  as  air  is 
bound  to  enter  and  be  retained.  In  aspirating  use  full  aseptic 
care.  When  it  is  wished  to  drain  the  abdomen,  the  latter 
should  always  be  opened  with  a  knife,  because  an  intestine 
might  happen  to  be  glued  to  the  abdominal  wall ;  hence  if 
a  trocar  or  a  needle  were  used  perforation  would  take  place. 
In  a  moderate  oedema  there  is  used  locally  compression,  and 
tincture  of  iodine  diluted  with  an  equal  bulk  of  alcohol. 
In  persistent  oedema  employ  frictions  with  a  stimulating  lini- 
m.ent.  Internally,  salines  and  diuretics  are  indicated.  The 
compound  jalap  powder  is  well  suited  to  dropsies.  Mercu- 
rials can  be  used,  and  in  severe  cases  also  elaterium. 

Effusion  of  Lymph. — The  term  "  lymph  "  is  a  synonym 
for  fibrinous  exudate,  coagulable  lymph,  plastic  infiltrate, 
solid  inflammatory  new  formation,  organized  new  formation, 
indifferent  tissue,  granulation-tissue,  or  embryonic  tissue. 
Here  we  have  effusion  of  highly  albuminous  liquor  san- 
guinis, with   proliferation  of  the  blood-corpuscles  and   the 


TERMINATIONS   OF  INFLAMMATION. 


83 


fixed  connective-tissue  cells  (Fig.  24).  Effusion  of  lymph 
means  a  more  severe  inflammation  than  does  the  effusion 
of  serum.  Lymph  may  be  absorbed  or  it  may  be  organized 
into  tissue.     If  it  becomes  organized,  capillaries  form  in  it 


Fig.  24. — Recent  Lymph,  forming  False 
Membrane  (Gross). 


Fig.  25. — Blood-vessels  in  Granula- 
tion (Gross). 


by  the  extension  from  the  surrounding  tissue  of  capillary 
loops,  which  raise  up  the  lymph  and  form  granulations.  A 
granulation  may  be  defined  as  a  small  mass  of  lymph  con- 
taining vessels  (Fig.  25). 

Lymph  is  divided  into  two  forms — plastic  or  foniiative 
lymph,  that  which  can  be  converted  into  tissue,  hence  that 
which  brings  about  repair ;  aplastic  or  croupous  lymph,  that 
which  develops  no  fibres  and  cannot  be  converted  into 
tissue,  and  which  in  consequence  cannot  bring  about  repair. 
Effusion  of  lymph  may  be  beneficial.  It  repairs  all  injuries  ; 
it  surrounds  and  encapsules  foreign  bodies ;  it  circumscribes 
abscesses  ;  and  it  often  prevents  pus  from  evacuating  into 
a  cavity,  gluing  together  structures  to  make  a  channel  and 
leading  the  pus  to  the  surface.  It  may  be  injurious.  It  forms 
adhesions  of  the  brain,  pleura,  peritoneum,  pericardium,  and 
joints ;  it  produces  opacity  in  the  cornea  and  adhesions  of 
the  iris  ;  it  constitutes  the  false  membrane  of  the  larynx  or 
trachea ;  and  it  causes  stricture  of  the  urethra  and  thicken- 
ing of  organs. 

Tveatnicut. — Locally,    employ    compression,    tincture    of 


84  A   MANUAL    OF  SUA'GEA'V. 

iodine,  lead-water  and  laudanum,  alternating  hot  and  cold 
douches,  friction,  and  massage;  also  ichthyol  and  lanolin. 
Internally,  use  mercurials  and  iodide  of  potassium  or  tartar 
emetic.  Prof  S.  W.  Gross  recommended  the  following  mix- 
ture for  inflammatory  thickening: 

Ijt.    Putassii  ioditli,  gr-  x  ; 

Ilydrarg.  chloridum  corros.,  gr.  y^^; 

Antimonii  et  potassii  tartras,  gr.  yL. — M. 

Sig.  Three  times  a  day,  in  half  a  glass  of  water,  after  meals. 

Suppuration  is  a  process  in  which  tissues  and  inflamma- 
tory exudates  are  liquefied  by  the  action  of  pyogenic  cocci, 
and  it  is  a  common  termination  of  infective  inflammation. 
Localized  suppurations  are  due  to  staphylococci ;  spreading 
suppurations,  to  streptococci.  Cocci  liquefy  exudates  and 
tissues  by  peptonizing  them.  Suppuration  can  be  induced 
by  the  injection  of  cocci,  by  their  entry  through  a  wound, 
and  by  rubbing  them  upon  the  skin.  In  some  rare  instances, 
especially  when  the  diet  has  been  putrid,  they  may  enter 
through  the  blood.  The  entry  of  cocci  does  not  necessarily 
mean  suppuration,  as  the  healthy  human  body  can  destroy  a 
moderate  dose,  but  a  large  dose  in  a  healthy,  or  even  a  small 
dose  in  an  unhealthy,  organism  almost  certainly  does.  The 
pus  of  all  acute  abscesses  contains  cocci,  but  the  pus  of 
tubercular  abscesses  does  not,  unless  there  be  a  mixed  in- 
fection ;  in  other  words,  pure  tubercular  pus  is  not  pus  at  all. 

Can  suppuration  be  induced  without  micro-organisms  ? 
It  is  true  that  the  injection  of  irritants  can  cause  the  forma- 
tion of  a  thin  fluid  which  contains  no  organisms,  but  this  non- 
bacterial pus  is  not  pus.  The  same  sort  of  fluid  is  formed 
by  injecting  cultures  of  cocci  which  have  been  rendered 
sterile  by  heat,  the  organisms  being  killed,  their  products 
being  the  active  agent.  Spurious  or  "  aseptic  "  pus  does  not 
concern  us,  as  it  is  never  found  practically.  Impaired  health 
or  an  area  of  lowered  vitality   predisposes  to  suppuration. 


TERMINATIONS    OF  INFLAMMATION.  85 

The  lymphatic  glands,  medulla  of  bones,  serous  membranes, 
and  connective  tissue  are  especially  prone  to  suppurate. 
When  a  medullary  canal  suppurates  as  a  result  of  a  blow 
that  does  not  cause  a  wound,  we  know  that  the  organisms 
must  have  arrived  by  means  of  the  blood. 

Pus  may  form  in  twenty-four  hours  after  an  inflanmiation 
begins,  of  it  may  not  form  for  days.  The  older  surgeons 
claimed  that  pus  could  do  good  by  protecting  granulations 
and  separating  disorganized  tissue.  It  is  now  held  that  it  is 
absolutely  harmful  by  melting  down  sound  tissue  and  poison- 
ing the  entire  organism.  Modern  surgery  has  to  a  great 
degree  abolished  pus. 

If  pus  stands  for  a  time,  it  separates  into  two  portions — 
(i)  a  watery  portion,  the  liquor  puris  or  pus-serum,  contain- 
ing peptone,  fat,  microbic  products,  osmazone,  and  salts,  and 
not  tending  to  coagulate  ;  (2)  a  sohd  portion,  or  sediment  of 
pus  cocci,  pus-corpuscles  (Fig.  26),  and  broken-down  tissue. 
The  pus-corpuscles  are  either  white  blood-cells  or  the  fixed 
cells  of  connective  tissue.  Some  of  them  are  dead,  some  have 
amoeboid  movements,  some  are  fatty,  others  are  granular  and 
contain  more  than  one  nucleus,  and  all  are  degenerating. 
A  pus-cell  is  waste  matter,  and  it  cannot  aid   in  repair. 

Forms  of  Pus. — Laudable  or  licalthy  pus,  a  name  long  in 
vogue,  is  a  contradiction,  no  pus  being  healthy.  In  former 
days  free  suppuration  after  an  operation  was  regarded  as  a 
favorable  indication,  showing  that  there  was  no  septicaemia, 
which  disease  dries  up  wound-discharges.  At  the  present 
day  suppuration  after  an  operation  is  an  evidence  of  previous 
infection,  of  unpardonable  lack  of  care,  or  of  infection  b}'  the 
blood.  This  form  of  pus  is  seen  coming  from  a  healing 
ulcer,  and  is  a  yellowish-white  or  a  greenish  fluid  of  the 
consistence  of  cream,  opaque,  with  a  very  slight  odor  if  it  is 
not  putrid,  and  has  a  specific  gravity  of  about  1.030. 

Malignant,  watery,  or  ichorous  pus  is  a  thin,  watery,  putrid 


86 


A    MANUAL    OF  SURGERY. 


fluid.     It  is  pus  rendered  putrid  by  the  organisms  of  putre- 
faction (bacterium  termo). 

Saiiious  pus  is  a  form  of  ichorous  pus  containing  blood 
coloring-matter  or  blood.     It  is  thin,  of  a  reddish  color,  and 


\(S) 


'       '^jf^ 


(&,.     ^'. 


^^^  ^ 


B,       V    '      _=■*-  V/ 


Fig.  26. — Fragmentation  of  Nucleus  in  Leucocytes  undergoing  Transformation  into  Pus- 
corpuscles  (Senn). 


very  acrid,  corroding  the  parts  that  it  comes  in  contact  with. 
It  is  found  notably  in  caries  and  carcinoma. 

Concrete  or  fibrinous  pus,  which  contains  flakes  of  fibrin 
or  coagulated  fibro-purulent  masses,  is  met  with  in  serous 
cavities  (joints,  pleura,  etc.).  These  masses  are  found  in 
infective  endocarditis  (Bowditch). 

Blue  pus. — The  color  of  blue  pus  is  due  to  the  bacillus 
pyocyaneus. 

Orange  pus,  which  is  due  to  ha^matoidin,  follows  violent 
inflammations  in  which  red  as  well  as  white  corpuscles  are 


TERMINATIONS   OF  INFLAMMATION.  8/ 

exuded,  these  corpuscles  being  broken  up  by  the  pyogenic 
cocci. 

Serous  pus  is  a  thin  serous  fluid  containing  a  few  flakes. 

Scrofulous  or  curdy  pus  is  not  pus  at  all,  unless  the  tuber- 
cular area  has  undergone  pyogenic  infection. 

Guiniiiy  pus  arises  from  the  breaking  down  of  a  gumma 
which  has  outgrown  its  own  blood-supply.     It  is  not  pus. 

Muco-pus  is  found  in  purulent  catarrh,  that  is,  in  suppura- 
tive inflammation  of  an  epithelial  structure.  It  contains  pus- 
elements  and  epithelial  cells. 

Caseous  pus  comes  from  the  fatty  degeneration  of  pus- 
corpuscles  or  inflammatory  exudations.  This  mass  may 
calcify.     It  occurs  in  tuberculous  processes. 

Contagious  pus  is  that  which  contains  and  conveys  the 
elements  of  some  specific  contagion,  such  as  small-pox  or 
a  chancroid. 

Suppuration  is  announced  by  the  intensification  of  all  in- 
flammatory signs.  Irregular  chills  and  drenching  sweats 
are  very  significant  of  suppuration  in  an  important  structure 
or  of  a  wide  area.  The  heat  becomes  intense,  the  discolora- 
tion becomes  dusky,  the  swelling  is  much  augmented,  the 
pain  becomes  throbbing  or  pulsatile,  and  there  is  an  increasing 
sense  of  tension.  The  skin  at  the  focus  of  the  inflammation 
becomes  adherent  to  the  parts  beneath,  and  fluctuation  soon 
appears.  This  adhesion  of  the  skin  is  a  preparation  for  a 
natural  opening,  and  is  what  is  known  as  "  pointing."  An 
important  sign  of  pus  beneath  is  oedema  of  the  skin.  This 
is  noticeable  in  empyema  or  pyothorax  and  appendicitis. 
The  above  symptoms  can  be  reinforced  and  their  significance 
proved  by  the  introduction  of  an  exploring-needle  and  the 
discovery  of  pus. 

Diffused  Cellulitis  or  Phlegmonous  Suppuration :  Purtdent 
Infiltration. — This  process  may  involve  a  small  area  or  an 
entire  limb.     It  is  announced  in  severe  cases  by  enormous 


8S  A    MANUAL    OF  SURGERY. 

swelling,  the  development  of  areas  which  feel  bo^^gy,  a 
dusky-red  discoloration,  great  burning  pain,  and  probably 
chills,  sweats,  and  fever.  Gangrene  of  superficial  areas  is  not 
unusual.  The  discharges  of  the  wound,  if  a  wound  exists, 
dry  up,  and  the  wound  becomes  dry  and  brown.  The  adja- 
cent lymphatic  glands  are  much  enlarged.  We  find  diffused 
suppuration  in  infected  compound  fractures,  in  extravasation 
of  urine,  and  after  the  infliction  of  a  wound  upon  a  person 
broken  down  in  health.  It  is  not  unusual  after  scarlet  fever, 
and  is  typical  of  phlegmonous  erysipelas.  The  pus  is  sani- 
ous  and  offensive.  This  diffused  suppuration  may  widely 
separate  muscles,  and  even  lay  bare  the  bones.  It  is  a  very 
grave  condition,  and  may  cause  death  by  exhaustion,  septic 
intoxication,  septic  infection,  pyemia,  or  hemorrhage  from 
a  large  vessel  which  has  been  corroded.  Cellulitis  of  a  mild 
degree  may  surround  an  infected  wound  or  a  stitch-abscess. 
Its  spread  is  manifested  by  red  lines  of  lymphangitis  run- 
ning up  to  the  adjacent  lymphatic  glands.  Light  cases  may 
not  suppurate,  the  lymphatics  carrying  off  the  poison.  Any 
case  of  cellulitis  is,  however,  a  menace,  and  any  severe  case 
is  highly  dangerous  (see  Erysipelas). 

Abscesses. — An  abscess  is  a  circumscribed  cavity  of  new 
formation  containing  pus.  We  emphasize  the  fact  that  it  is 
a  circinnscrihcd  cavity — circumscribed  by  embryonic  tissue. 
A  purulent  infiltration  is  not  circumscribed,  hence  it  does 
not  constitute  an  abscess.  An  essential  part  of  the  definition 
is  the  assertion  that  the  pus  is  in  a  cavity  of  nezv  formation, 
in  an  abnormal  cavity  ;  hence  pus  in  a  natural  cavity  (pleural, 
pericardial,  synovial,  or  peritoneal)  constitutes  a  purulent 
effusion,  and  not  an  abscess. 

An  acute  abscess  is  due  to  the  deposition  and  multiplica- 
tion of  pyogenic  cocci  in  the  tissues  or  in  inflammatory 
exudates.  These  cocci  attack  exudates  or  tissues,  form  irri- 
tants which  intensify  the   inflammation,  and  by  exerting  a 


Plate  2. 


I.  Infiltration  of  Connective  Tissue  of  Cutis  (X  500),  with  beginning  suppuration  in  the  centre 
(Senn).  2.  Embolus  Impacted  at  Bifurcation  of  a  Branch  of  the  Pulmonary  Artery  (Green).  3. 
Thrombus  in  the  Saphenous  Vein  (Green).     4.  Marasmic  Rickets  (Pye). 


TERMINATIONS    OF  INFLAMMATION.  89 

peptonizing  action  on  intercellular  substance  and  fibrin  of  the 
exudate  liquefy  tissue  and  the  products  of  inflammation  and 
form  pus.  Within  twenty-four  hours  after  their  lodgment 
the  exudation  increases  in  amount,  the  migrated  leucocytes 
are  found  in  enormous  numbers,  the  fibres  of  tissue  swell  up, 
and  the  connective-tissue  spaces  are  distended  with  cells  and 
fluid.  The  connective-tissue  cells,  acted  on  by  pus  cocci, 
multiply  by  karyokinesis,  develop  many  nuclei,  lose  their 
stellate  projections,  degenerate,  and  constitute  one  form  of 
pus-corpuscle,  leucocytes  forming  the  rest.  All  the  small 
vessels  are  choked  with  leucocytes,  this  blocking  serving  to 
cut  off  nourishment  and  tending  to  produce  anaemic  necrosis. 
Liquefaction  occurs  at  many  foci  of  the  inflammation,  drops 
of  pus  being  formed,  the  amount  of  each  being  progres- 
sively added  to  and  many  foci  coalescing  (PI.  2,  Fig.  i).  The 
pus-cavity  is  circumscribed,  not  by  a  secreting  pyogenic 
membrane,  but  by  embryonic  tissue  whose  cells  and  inter- 
cellular material  have  not  as  yet  broken  down,  and  this  area 
of  embryonic  tissue  is  circumscribed  by  a  zone  of  inflamma- 
tion. As  an  abscess  increases  in  size  the  embryonic  tissue 
from  within  outward  liquefies  into  pus,  and  the  zone  of  inflam- 
mation beyond  continually  enlarges  and  forms  more  lymph. 
After  a  time  the  inflammation  reaches  the  surface,  the  embry- 
onic tissue  glues  the  superficial  to  the  deeper  parts,  liquefac- 
tion of  this  lymph  occurs,  a  small  elevation  due  to  fluid 
pressure  appears  (pointing),  and  this  elevation  thins  and 
breaks  from  tension  and  liquefaction  (spontaneous  evacua- 
tion). When  an  abscess  forms  in  an  internal  organ  or  in 
some  structure  which  is  not  loose  like  connective  tissue — 
for  instance,  in  a  lymphatic  gland — a  mass  of  pus  cocci, 
floating  in  the  blood  or  lymph,  lodges,  and  these  cocci  by 
means  of  irritant  products  cause  coagulation  necrosis  of  the 
adjacent  tissue  and  inflammatory  exudation  around  it.  The 
area  of  coagulation  necrosis  becomes  filled  with  white  blood- 


90  A   MANUAL    OF  SURGERY. 

cells,  and  the  dry  necrosed  part  is  liquefied  by  the  cocci. 
Suppuration  in  dense  structures  causes  considerable  masses 
of  tissue  to  die  and  to  be  cast  off,  and  these  masses  float 
in  the  pus.  Death  of  a  mass  with  dissolution  of  its  ele- 
ments is  necrosis  or  inflammatory  gangrene. 

Forms  of  Abscesses. — The  following  are  the  various 
forms  of  abscesses  :  acute  or  pJilcgmonous,  which  follows  an 
acute  inflammation  ;  stnnnous^  cold,  lyinpliatic,  tubercular,  or 
chronic  abscess  is  due  to  tubercle,  and  does  not  contain  true 
pus  without  there  is  secondary  infection.  It  presents  no  signs 
of  inflanmiation.  A  lymphatic  abscess  may  form  in  a  week 
or  two,  and  hence  is  not  necessarily  chronic,  which  term 
may  mean  a  persistent  non-tubercular  abscess ;  caseous  or 
cheesy  abscess,  a  cavity  containing  thick  cheesy  masses,  is  due 
to  the  breaking  down  of  tubercular  matter ;  circumscribed 
abscess  is  one  limited  by  embryonic  tissue ;  diffused  abscess 
is  a  collection  of  pus  unlimited  by  lymph  ;  congestive,  gravi- 
tative,  luanderiug,  or  hypostatic  abscess  is  a  condition  in  which 
the  pus  travels  from  its  formation-point  and  appears  at 
some  distant  spot  (as  a  psoas  abscess) ;  critical  or  consecutive 
abscess  is  one  which  arises  during  an  acute  disease  ;  diathetic 
abscess  is  due  to  a  diathesis;  embolic  abscess  is  due  to  in- 
fected emboli ;  tympanitic  or  emphysematous  abscess  is  one 
which  contains  the  gases  of  putrefaction  ;  encysted  abscess,  in 
which  pus  is  circumscribed  in  a  serous  cavity ;  fecal  or  ster- 
coraceous  abscess  is  one  containing  feces  because  of  a  com- 
munication with  the  bowel;  follicidar  3hscQss  is  one  arising 
in  a  follicle;  hcematic  abscess  is  that  which  arises  around 
blood-clot,  as  a  suppurating  hsematoma  ;  marginal  abscess, 
which  appears  upon  the  margin  of  the  anus  ;  pycemic  or 
metastatic  abscess  is  the  embolic  abscess  of  pyaemia ;  nnlk 
abscess  is  an  abscess  of  the  breast  in  a  nursing  woman ; 
ossifluent  abscess,  arising  from  diseased  bone ;  psoas  abscess, 
arising  from  vertebral  caries,  following  the  psoas  muscle  and 


TERMINATIONS   OF  INFLAMMATION.  9 1 

usually  pointing  in  the  groin ;  sympathetic  abscess,  arising 
some  distance  from  the  exciting  cause,  such  as  a  suppurating 
bubo  ■  from  chancroid ;  tliccal  abscess  is  suppuration  in  a 
tendon-sheath ;  tropical  abscess  is  an  abscess  of  the  liver,  so 
named  because  it  occurs  in  tropical  countries.  It  usually 
follows  dysentery ;  urinary  abscess,  caused  by  extravasated 
urine;  verminous  abscess,  one  which  contains  intestinal  worms 
and  communicates  with  the  bowel ;  syphilitic  abscess,  which 
occurs  in  the  bones  during  tertiary  syphilis  ;  Brodie's  abscess 
is  a  chronic  abscess  of  a  bone,  most  common  in  the  head 
of  the  tibia;  ^?//<f;7f^/(^/ abscess,  which  occurs  above  the  deep 
fascia ;  deep  abscess,  occurring  below  the  deep  fascia ;  and 
residual  or  Paget' s  abscess,  a  recurrence  of  suppuration,  it 
may  be  after  years,  about  the  residue  of  a  former  abscess. 

Acute  Abscess. — In  an  acute  abscess  a  part  becomes  in- 
flamed and  embryonic  tissue  forms ;  this  is  liquefied  (as 
above  noted)  and  laudable  pus  is  produced.  If  the  abscess 
is  in  the  brain,  in  the  tonsils,  or  in  the  neighborhood  of  the 
rectum,  the  odor  of  the  pus  is  apt  to  be  offensive.  An  acute 
abscess  can  occur  in  a  person  of  any  constitution. 

Symptoms :  Local  Symptoms. — Locally  there  is  intensifica- 
tion of  inflammatory  signs  :  swelling  enormously  increases, 
the  discoloration  becomes  dusky,  the  pain  becomes  throbbing 
and  the  sense  of  tension  increases,  and  the  cutaneous  surface 
is  seen  to  be  polished  and  oedematous. 

Constitutional  Symptoms. — In  cases  of  small  collections  of 
pus  in  unimportant  structures  there  may  be  no  obvious  con- 
stitutional disturbance.  If  the  abscess  contains  much  pus  or 
affects  an  important  part,  generally  disturbances  appear,  from 
slight  rigors  or  moderate  fever  to  chills,  high  temperature, 
and  drenching  sweats.  The  constitutional  condition  typical 
of  an  abscess  is  due  to  the  absorption  of  retained  elements 
of  pus,  and  this  is  known  as  "suppurative  fever."  When 
suppuration  is  long  continued,  there  exists  a  fever  which  is 


92  A   MANUAL    OF  SURGERY. 

markedly  periodic :  the  temperature  rises  in  the  evening, 
attaining  its  highest  point  usually  between  4  and  8  p.  m.,  and 
then  sinks  to  normal  or  nearly  normal  in  the  early  morning 
(from  4  to  8  A.  m.).  When  the  temperature  begins  to  fall 
profuse  perspiration  takes  place.  This  fever  is  known  as 
"  hectic." 

The  symptoms  of  an  abscess  are  somewhat  modified  by 
location.  Bone  never  suffers  from  acute  abscess ;  sudden 
and  violent  inflammations  produce  necrosis,  and  all  bone- 
abscesses  are  chronic — that  is,  slow  in  formation  and  pro- 
longed in  duration.  Pain  is  continued,  but  not  usually 
severe ;  it  is  boring  in  character  and  variable  in  intensity, 
being  worse  at  night.  Attacks  of  synovitis  are  apt  to  arise 
in  the  adjacent  joint.  In  abscess  of  a  silent  region  of  the 
brain,  symptoms  may  long  be  entirely  absent.  The  usual 
symptoms  are  headache,  vomiting,  delirium,  drowsiness,  optic 
neuritis,  and  often  a  subnormal  temperature.  Localizing 
symptoms  may  be  present.  In  but  few  cases  are  there  fever 
and  sweats. 

Appendicinal  abscess  results  from  ulceration  and  perfora- 
tion of  the  vermiform  appendix,  aplastic  peritonitis  circum- 
scribing the  pus.  Its  signs  are  pain,  tenderness,  often  swell- 
ing, dulness  on  percussion,  and  sometimes  fluctuation  and 
skin-oedema  in  the  right  iliac  fossa,  fever,  vomiting,  some- 
times constipation,  and  sometimes  diarrhoea.  Stercoraceous 
vomiting  does  not  occur. 

Abscess  of  tlie  liver  ma\'  not  be  announced  by  symptoms 
until  rupture.  We  may  find  fever  of  an  intermittent  type, 
profuse  sweats,  pain  in  the  back,  the  shoulder,  or  the  right 
hypochondriac  region,  enlargement  of  the  area  of  liver- 
dulness,  hepatic  tenderness,  and  finally  sepsis.  Sometimes 
there  is  fluctuation  and  skin-oedema,  the  skin  being  a  little 
jaundiced.  The  symptoms  vary  as  the  pus  invades  adjacent 
organs. 


TERMINATIONS   OF  INFLAMMATION  93 

Abscess  of  the  lung  gives  the  physical  signs  of  a  cavity ; 
the  expectoration  is  offensive  and  contains  fragments  of  lung- 
tissue.'     Pyaemic  abscesses  may  not  be  discovered. 

Abscess  of  the  viediastinuni  causes  throbbing  retro-sternal 
pain,  chills,  fever,  sweats,  and  often  dyspnoea.  A  tumor  may 
appear  which  pulsates  and  fluctuates. 

Perinephric  abscess  usually  causes  tenderness  and  pain  in 
the  lumbar  region  or  about  the  hip-joint,  running' down  the 
thigh  and  accompanied  by  retraction  of  the  testicle.  Indu- 
ration, fluctuation,  or  oedema  of  the  skin  may  appear. 
The  constitutional  symptoms  of  suppuration   usually  exist. 

Retropharyngeal  abscess  causes  cough,  dyspnoea,  pain  on 
swallowing,  dysphagia,  and  altered  voice ;  an  examination 
discloses  a  projection  on  the  posterior  wall. 

Abscess  of  the  antnun  of  Highniore  causes  pain,  oedema- 
tous  swelling,  and  crepitation  on  pressure. 

Abscess  of  the  larynx  induces  violent  cough,  pain,  inter- 
ference with  the  voice,  swallowing,  and  breathing,  and  is  seen 
with  a  laryngoscope. 

Prostatic  abscess  is  manifested  by  chills,  fever,  and  sweats, 
developing  during  an  attack  of  acute  prostatitis. 

Diagnosis. — The  diagnosis  of  an  abscess  rests  upon — 
(i)  its  history;  (2)  fluctuation;  (3)  pointing;  (4)  surface- 
oedema;  and  (5)  the  use  of  the  exploring-needle. 

A  suspected  abscess  in  a  dangerous  or  important  part 
under  no  circumstance  should  be  opened  by  a  bistoury 
without  knowing  that  our  diagnosis  is  certainly  correct. 
This  knowledge  is  obtained  by  inserting  an  exploring-needle 
and  finding  the  nature  of  the  fluid  which  exudes.  An 
abscess  made  to  move  with  the  pulse  by  resting  upon  an 
artery  may  be  confounded  with  an  aneurysm.  The  pulse- 
movements^of  an  abscess  are  in  one  direction  only,  it  does 
not  enlarge,  and  if  a  finger  is  laid  upon  either  side  of  it  the 
fingers  will  be  lifted,  but  not  separated.     The  pulse-move- 


94  ^   MANUAL    OF  SURGERY. 

ments  of  an  aneurysm  arc  in  all  directions ;  they  are  pul- 
satile, the  tumor  grows  larger,  and  the  fingers  will  not  only 
be  lifted,  but  will  also  be  separated.  The  exploring-needle 
must  be  used :  it  will  do  no  harm  to  an  aneurysm  if  aseptic. 
A  rapidly-growing,  small-celled  sarcoma  feels  not  unlike  an 
abscess ;  but  the  exploring-needle  discovers  blood,  and  not 
pus.  A  cystic  tumor  is  separated  from  an  abscess  by  the 
absence  of  inflammation,  or,  if  it  inflames,  by  the  nature  of 
the  fluid  it  contains.  Ordinary  caution  will  prevent  us  from 
confounding"  an  abscess  and  strangulated  hernia.  A  cold 
abscess  is  separated  from  an  acute  abscess  by  the  absence 
of  inflammatory  signs. 

Prognosis. — The  prognosis  varies  according  to  the  number 
of  abscesses,  their  location  and  size,  and  the  strength  of  the 
patient. 

Treatment. — In  the  treatment  of  an  abscess  there  is  one 
absolute  rule  which  knows  no  exception,  namely,  that  when- 
ever and  wherever  pus  is  found  the  abscess  should  be  evacu- 
ated at  once,  and,  after  evacuating  it,  thorough  drainage 
provided  for.  It  should  be  opened  early,  if  possible  even 
before  pointing  or  fluctuation,  to  prevent  tissue-destruction, 
subfascial  burrowing,  and  general  contamination.  In  puru- 
lent effusion  into  the  pleural  cavity  (empyema  or  pyothorax), 
resect  a  portion  of  a  rib,  cut  away  periosteum,  incise  the 
pleura,  evacuate  the  pus,  wash  out  the  cavity  first  with  a 
14-volume  solution  of  peroxide  of  hydrogen  diluted  with 
an  equal  bulk  of  water,  then  with  a  I  :  3000  solution  of  cor- 
rosive sublimate,  then  with  boiled  water ;  insert  a  drainage- 
tube,  dress  antiseptically,  and  immobilize  the  chest  with  a 
binder,  washing  out  afresh  every  day.  If  there  be  a  large 
pus-cavity,  resect  a  portion  of  each  overlying  rib  to  permit 
of  sinking  in  of  the  chest-wall  and  approximation  of  the  sides 
of  the  pus-cavity  (Estlander's  operation).  Operations  by  the 
trocar  or  aspirator  are  rarely  curative.     In  purulent  perito- 


terminatiojYs  of  inflammation.  95 

nitis,  open  the  abdomen  and  flush  well  with  boiled  water, 
insert  a  drainage-tube,  and  wash  out  the  abdomen  every  day. 

Abscess  of  the  liver  requires  that  an  incision  be  made 
along  the  edge  of  the  ribs  down  to  the  liver,  which  organ 
is  then  stitched  to  the  edges  of  the  wound,  the  abscess 
opened  and  washed  out,  and  a  tube  inserted.  Appendicular 
abscess,  abscess  of  lung,  of  mediastinum,  etc.,  like  all  other 
abscesses,  require  incision  and  drainage.  In  abscess  of  the 
brain  the  skull  should  be  trephined,  the  membranes  incised, 
and  the  abscess  sought  for,  opened,  and  drained.  *  In  bone- 
abscess  the  bone  must  be  trephined.  In  an  ordinary  super- 
ficial abscess,  after  cleansing  the  parts,  make  the  skin  tense, 
incise  with  a  sharp-pointed  curved  bistoury,  and  let  the  pus 
run  out  itself,  pressure  being,  as  a  rule,  undesirable.  If  tis- 
sue-shreds block  up  the  opening,  they  must  be  picked  out 
with  forceps.  If  the  atmospheric  pressure  will  not  cause  the 
pus  to  flow  out,  make  light  pressure  with  warm,  moist, 
aseptic  sponges.  After  the  pus  has  come  away,  wash  the 
cavity  with  peroxide  of  hydrogen  and  then  with  corrosive 
solution  (I  :  looo),  and  pack  with  iodoform  gauze  for  two 
or  three  days,  when  the  discharge  becomes  serous.  Pursue 
rigid  antisepsis  in  dealing  with  pus.  It  is  true  w^e  already 
have  infection,  but  we  can  easily  infect  with  organisms  of 
putrefaction,  making  putrid  pus.  In  a  deep  abscess  always 
use  a  drainage-tube  for  several  days. 

In  a  deep  abscess  or  an  abscess  situated  near  important 
vessels,  do  not  boldly  plunge  in  a  knife.  Hilton  says  to 
"plunge  in  a  knife  is  not  courageous,  as  it  is  without  danger 
to  the  surgeon,  but  may  be  fatal  to  the  patient."  Remember 
also  that  a  large  amount  of  pus  displaces  normal  anatomical 
relations.  Hilton's  method  of  opening  a  deep  abscess  (as  in 
the  axilla  o1r  neck)  is  to  cut  through  the  deep  fascia  and 
then  to  push  into  the  abscess  a  grooved  director  until  pus 
shows  in  the  groove ;  along  this  groove  push  a  pair  of  dress- 


96  A   MANUAL    01'   SUKGEKY. 

ing-forccps,  shut ;  after  they  reach  the  depths  open  them 
and  withdraw,  and  so  dilate  the  openin<^ ;  then  insert  a  tube 
and  wash.  In  an  abscess  in  the  posterior  part  of  the  orbit, 
after  incising  transversely  a  portion  of  the  upper  lid,  the 
abscess  should  be  reached  by  this  method.  Always  endeavor 
to  open  an  abscess  at  its  most  dependent  part,  remembering 
that  this  may  depend  upon  whether  the  patient  is  erect  or 
recumbent.  If  we  do  not  make  the  opening  at  the  lowest 
point,  all  the  pus  will  not  run  out  and  the  walls  will  not 
completely  collapse. 

In  post-pharyngeal  abscess  opening  through  the  mouth 
is  dangerous,  as  pus  may  enter  the  larynx.  In  these  cases 
it  is  better,  as  Hilton  advised,  to  cut  down  through  the 
sterno-cleido-mastoid  muscle  to  the  fascia  below  it  and  push 
the  director  and  forceps  through  this  into  the  abscess. 
When  an  abscess  contains  diverticula  or  pouches,  the  latter 
should  be  slit  up  or  a  counter-opening  be  made.  A  counter- 
opening  is  made  by  entering  the  dressing-forceps  at  our  first 
incision,  pushing  them  through  the  abscess  to  the  point 
where  we  wish  to  make  our  counter-opening,  opening  the 
blades,  and  cutting  between  them  from  without  inward.  The 
blades  are  then  closed  and  projected  through  the  incision ; 
they  are  opened  to  dilate  the  new  door,  and  closed  again  upon 
a  drainage-tube  which  is  pulled  through  from  opening  to 
opening  as  the  instrument  is  withdrawn.  In  empyema  from 
a  wound  make  a  counter-opening  by  resecting  a  rib.  When 
pus  burrows,  insert  a  grooved  director  in  each  channel  and 
slit  it  up  with  a  knife. 

Rest  is  of  the  first  importance  in  the  healing  of  an  abscess, 
and  we  try  to  obtain  it  by  bandages,  splints,  and  pressure 
which  will  immobilize  adjacent  muscles  and  approximate 
the  abscess-walls.  If  an  abscess  is  slow  to  heal,  use  as  a 
daily  injection  peroxide  of  hydrogen  followed  by  I  :  500 
corrosive  sublimate,  or  3  drops  of  nitric  acid  to  5j  of  water, 


TERMINATIONS   OF  INFLAMMATION.  97 

or  3  grains  of  zinc  sulphate  to  5J  of  water,  or  a  5  per  cent, 
solution  of  carbolic  acid,  or  a  solution  of  pyoktanin,  5j  of  the 
concentrated  solution  to  Oj  of  water,  or  20  drops  of  tincture 
of  iodine  to  5J  of  water.  The  constitutional  treatment  of 
an  abscess  depends  upon  its  severity  and  upon  the  import- 
ance of  the  structures  involved.  In  a  bad  case  the  patient 
should  be  put  to  bed,  opiates  given  with  a  free  hand,  the 
bowels  kept  active  by  calomel  and  salines,  skin-activity  main- 
tained, nutritious  food  insisted  on,  and  stimulants  liberally 
employed. 

Tubercular  abscess,  called  also  chronic,  cold,  scrofulous, 
and  lymphatic,  is  an  abscess  circumscribed  by  a  distinct 
membrane.  Ashurst  says  that  the  term  *'  chronic  "  is  a  bad 
one.  "  It  refers  etymologically  only  to  time.  A  phlegmon- 
ous abscess,  if  deeply  seated,  may  be  of  slower  development 
than  a  chronic  or  cold  abscess  which  is  superficial."  A 
tuberculous  abscess  is  most  common  in  the  lymphatic  glands, 
bones,  joints,  and  subcutaneous  connective  tissues,  and  is  rare 
after  the  twentieth  year.  It  may  contain  quarts  of  curdy  pus. 
The  bacilli  of  tubercle  cause  inflammation,  and  embryonic 
tissue  is  formed,  which  undergoes  coagulation  necrosis  and 
caseation  because  of  the  irritation  of  ptomaines  and  anaemia 
due  to  the  mass  outgrowing  its  own  blood-supply.  First 
there  forms  from  embryonic  tissue  a  cheesy  matter  which 
is  liquefied  into  scrofulous,  curdy,  or  tubercular  pus.  This 
really  is  not  pus,  as  the  tubercle  bacillus  is  not  pyogenic ; 
if  true  pus  forms,  it  is  because  of  a  secondary  infection  with 
pus  cocci — an  accident,  and  not  a  part  of  the  natural  process 
of  formation  of  a  cold  abscess.  A  cold  abscess  may  be 
absorbed,  or  may  become  encapsuled  by  fibrous  organization 
of  its  limiting  lymph  into  the  pyogenic  membrane. 

Symptoms. — The  term  cold  abscess  is  employed  for  a 
tubercular  abscess  because  it  presents  no  inflammatory  signs. 
There  is  no   local   heat;    no   discoloration    unless   pointing 


98  ^   MANUAL    OF  SURGERY. 

occurs;  the  parts  look  paler  than  natural;  pain  is  absent 
in  the  abscess,  though  it  may  exist  at  the  point  of  origin  of 
the  pus ;  the  pus  wanders  from  its  point  of  origin  under 
the  influence  of  gravity ;  fluctuation  is  present  unless  thick 
walls  mask  it.  Constitutional  symptoms  are  absent  unless 
secondary  infection  occurs.  The  tumor  may  suddenly  appear 
in  some  spot — the  groin,  for  instance.  The  abscess  may  last 
for  years  without  producing  pain  or  annoyance.  The  explor- 
ing-needle  will  settle  the  diagnosis.  The  constitution  is  in- 
variably below  normal  because  of  the  tuberculous  infection, 
and  the  temperature  is  a  little  above  normal.  A  cold  abscess 
which  is  infected  with  pus  cocci  exhibits  great  inflammation, 
and  fever  rapidly  develops.  In  tubercular  disease  of  the 
vertebra  the  fluid  may  find  its  way  to  the  lumbar  region, 
to  the  iliac  region,  or  to  the  immediate  neighborhood  of 
Poupart's  ligament,  above  or  below  it. 

Retro-pharyngeal  or  post-pharyngeal  abscess  is  usually  due 
to  caries  of  the  cervical  vertebra.  A  tumor  projects  from  the 
posterior  pharyngeal  wall,  and  there  is  great  interference  with 
respiration  and  deglutition.  Pus  from  caries  of  the  cervical 
vertebrae  may  reach  the  posterior  mediastinum  by  following 
the  oesophagus,  or  it  may  appear  in  front  of  or  behind  the 
sterno-mastoid  muscle   (Edmund  Owen). 

Dorsal  Abscess. — The  pus  in  dorsal  abscess  arises  from 
dorsal  caries,  flows  into  the  posterior  mediastinum,  and 
reaches  the  surface  by  passing  between  the  transverse  pro- 
cesses. The  pus  from  dorsal  caries  may  run  forward  be- 
tween the  intercostal  muscles  or  between  these  muscles  and 
the  pleura,  pointing  in  an  intercostal  space  at  the  side  of  the 
sternum  or  by  the  rectus  muscle.  It  may  open  into  the 
gullet,  windpipe,  bronchus,  pleura,  or  pericardium.  It  may 
descend  to  the  diaphragm  and  travel  under  the  inner  arcuate 
ligament  to  form  a  psoas  abscess,  or  under  the  outer  arcuate 
ligament  to  form  a  lumbar  abscess.    A  psoas  abscess  points 


TERMINATIONS    OF  INFIAMMATION  99 

external  to  the  femoral  vessels,  and  is  thus  distinguished 
from  a  femoral  hernia. 

Iliac  abscess  comes  from  lumbar  caries,  the  tumor  lying 
in  the   iliac   fossa   and  pointing    above  Poupart's    ligament. 

Psoas  abscess  is  usually  due  to  lumbar  caries,  the  pus 
pointing  in  Scarpa's  triangle  external  to  the  femoral  vessels. 
A  psoas  or  iliac  abscess  by  following  the  lumbo-sacral  cord 
and  great  sciatic  nerve  forms  a  gluteal  abscess.  These 
abscesses  may  open  mto  the  bowel,  bladder,  ureter,  or  peri- 
toneal cavity. 

Lzunbar  Abscess. — In  a  lumbar  abscess  the  pus  from  dorsal 
caries  descends  beneath  the  outer  arcuate  ligament,  or  the 
pus  from  lumbar  caries  which  collected  anterior  to  or  in  the 
quadratus  lumborum  muscle  flows  backward  between  the 
last  rib  and  iliac  crest  in  the  triangle  of  Petit.^ 

Treatment. — If  a  small  cold  abscess  exists  in  a  superficial 
structure,  open  it  with  aseptic  care,  curette  its  walls,  wash 
out  with  I  :  1000  mercurial  solution,  pack  with  iodoform 
gauze,  and  dress  antiseptically.  In  a  day  or  two  remove  the 
gauze,  but  continue  mercurial  dressings.  If  it  be  slow  in 
healing,  inject  or  swab  out  wnth  a  stimulating  fluid  as  in 
acute  abscess. 

Cold  Abscess  of  Lymphatic  Glands. — In  non-exposed  por- 
tions of  the  body  the  capsule  should  be  incised,  dissected 
and  scraped  away,  and  the  cavity  swabbed  out  with  pure 
carbolic  acid  and  packed  wnth  iodoform  gauze.  If  the 
abscess  is  allowed  to  burst,  it  will  make  an  ugly  scar ;  there- 
fore in  exposed  portions  of  the  body  an  effort  should  be 
made  to  prevent  a  scar.  When  only  a  little  pus  exists  and 
the  skin  is  not  discolored,  prepare  the  parts  antiseptically 
and  carry  a  silk  thread  bv  means  of  a  needle  throuc^h  the 
skin,  through  the  gland,  and  out  at  its  lowest  point.      Dress 

^  For  a  lucid  description  of  these  abscesses  see  Owen's  Manual  of  Anatomy, 
from  which  the  above  is  condensed. 


lOO  A   MANUAL    OF  SURGERY. 

with  gauze.  In  three  days  the  thread  can  be  taken  out  and 
a  firm  compress  applied.  When  the  gland  is  almost  entirely 
broken  down  and  the  skin  above  it  is  purple  and  thin,  insert 
a  hypodermatic  needle  through  sound  skin  into  the  abscess, 
draw  off  the  pus,  and  inject  iodoform  emulsion  (lo  per  cent, 
of  iodoform,  90  per  cent,  of  glycerin  or  olive  oil).  This  pro- 
cedure is  to  be  repeated  when  pus  again  accumulates.  By 
this  means  we  can  often  effect  a  cure  in  a  week  or  so.  When 
an  abscess  breaks  or  is  at  the  point  of  breaking,  cut  away 
all  purple  skin,  curette  the  abscess-walls  (the  abscess  having 
become  a  scrofulous  ulcer),  remove  all  remains  of  gland  and 
capsule,  swab  it  with  pure  carbolic  acid,  and  dress  with 
iodoform  and  corrosive  gauze. 

Large  Cold  Abscesses, — In  view  of  the  facts  that  these 
abscesses  may  cause  no  trouble  for  years  and  that  an  opera- 
tion may  be  fatal,  some  eminent  surgeons  are  opposed  to  an 
operation  unless  the  abscess  is  marching  toward  inevitable 
rupture  or  is  disturbing  the  functions  of  organs  by  pressure. 
Most  practitioners  believe,  however,  that  this  mass  of  tuber- 
culous matter  is  a  source  of  danger  through  being  a  depot 
of  infective  organisms  which  may  overwhelm  the  system, 
and  that  death  will  not  occur  in  the  hands  of  the  operator 
who  employs  with  intelligence  strict  antisepsis.  In  no  other 
cases  is  attention  to  every  detail  more  important,  as  infection 
is  very  easy,  and  probably  means  death. 

In  many  cases  aspiration  can  be  employed  to  empty  the 
cavity,  after  the  pus  runs  out,  injecting  either  a  10  per  cent, 
iodoform  emulsion  to  the  amount  of  5iij,  or  5iij  of  a  5  per  cent, 
ethereal  solution  of  iodoform.  After  injecting  the  emulsion 
squeeze  and  manipulate  the  fluid  into  every  nook  and  cranny. 
The  American  Text-book  of  Surgery  advises  the  injection  of 
from  I  to  3  ounces  of  the  following  preparation  :  Iodoform, 
10  parts  ;  glycerin,  20  ;  mucil.  gum  Arab.,  5  ;  carbolic  acid,  I ; 
water,  100. 


ULCERATION  AND   FISTULA.  lOI 

Whatever  fluid  is  chosen,  the  operation  must  be  repeated 
three  or  four  times  at  intervals  of  four  weeks.     It  is  danger- 
ous  to  inject  large  amounts  of  iodoform,  as  poisoning  will 
be   produced.     When   iodoform  poisons,  the   patient   has  a 
metalHc  taste  in  his  mouth,  subjective  foul  odors  in  the  nose, 
the  nose  and  eyes  water,  and  the  stomach  is  disturbed.     In 
bad  cases  we  find  insomnia,  loss  of  memory,  variable  emo- 
tions, headache,  and  violent  mania  alternating  with   coma. 
If  aspiration  and   injection   fail,  open,  under  rigid  antisepsis, 
the  most  dependent  portion  of  the  abscess,  scrape  it  well, 
and  over-distend  with  a  i  :  looo  solution  of  warm  corrosive 
sublimate,  which  should  be  washed   out  with  warm   boiled 
water.     With   a   long  probe   find   the   highest  point  of  the 
cavity,  and  make  a  counter-opening,  scrape  well,  search  for 
and   remove   carious  bone,  flush   out  the   whole   area   with 
corrosive  sublimate,  wash   out  this  mercurial  solution  with 
boiled  water,  and  either  make  tube-drainage  from  opening  to 
counter-opening  and  from   bone  to  counter-opening  or  pack 
the  entire  cavity  with   iodoform   gauze.     If  hemorrhage  is 
severe,  after  injecting  with  hot  water  the  opening  must  be 
packed.     When  a  large  abscess  breaks  of  itself,  it  should  at 
once  be  drained  and  asepticized  as  above.     In  the  treatment 
of  a  cold  abscess  give  nutritious  food,  cod-liver  oil,  quinine, 
iron,  and  the  mineral  acids.     Removal  to  the  sea-side  is  often 
indicated,  and  mechanical  appliances  may  be  needed  for  dis- 
eases of  the  bones  and  joints.     If  secondary  infection  does 
occur,  the  patient  develops  hectic  fever  (q.  v.). 


VI.   ULCERATION   AND    FISTULA 
An  ulcer  is  a  loss  of  substance  due  to  necrosis  of  a  super- 
ficial structure.     The  action  of  the  pus  cocci  is  the  same 
as  in  an  abscess.     A  broken  abscess  becomes  an  ulcer,  and 
an  ulcer  is  a  half-section  of  an   abscess.     The  floor  of  an 


I02  A   MANUAL    OF  SURGERY. 

ulcer  consists  of  embryonic  tissue  and  corresponds  with 
the  abscess-wall.  An  abscess  arises  from  molecular  death 
in  the  tissues;  an  ulcer,  from  molecular  death  of  a  free  sur- 
face. An  ulcer  must  not  be  confounded  with  an  excoriation. 
In  an  ulcer  the  corium  is  always,  and  the  subcutaneous  tis- 
sue is  generally,  destroyed,  and  a  scar  is  left  after  healing. 
In  an  excoriation  the  mucous  layer  of  epithelium  is  exposed, 
or  this  is  destroyed  and  the  corium  exposed.  The  corium 
is  never  destroyed,  and  no  scar  remains  after  healing. 

Necrosis  can  arise  from — (i)  Inflammation.  The  pressure 
of  the  exudate  can  cut  off  the  circulation,  or  bacteria  may 
directly  destroy  tissue.  Suppuration  occurs.  (2)  The  action 
of  pus  cocci,  causing  primary  cell-necrosis.  (3)  Bacteria  of 
putrefaction  and  cocci  of  suppuration  acting  upon  a  wound. 
(4)  Traumatism  or  irritants,  producing  at  once  stasis,  which 
is  added  to  by  secondary  inflammation,  the  exudate  under- 
going purulent  liquefaction.  (5)  Prolonged  pressure.  (6) 
Deficient  blood-supply.  (7)  Faulty  venous  return.  (8)  De- 
generation of  a  neoplastic  infiltration  (gummatous,  malig- 
nant, or  tubercular).  (9)  Trophic  disturbance.  (10)  Nutri- 
tional disturbances  (as  scurvy).  Most  ulcers  are  due  to  pus 
cocci,  and  even  those  that  arise  from  something  else  (as 
gummatous  degeneration)  are  apt  to  suppurate. 

Classification. — Ulcers  are  classified  into  groups  accord- 
ine  to  the  condition  of  the  ulcer  and  the  associated  con- 
stitutional  state.  In  the  first  group  we  find  the  varicose, 
hemorrhagic,  acute,  chronic,  irritable,  neuralgic,  etc.  In  the 
second  group  are  placed  the  strumous,  syphilitic,  senile, 
scorbutic,  etc.  All  ulcers,  whatever  their  origin,  are  either 
acute  or  chrojiic,  and  such  conditions  as  great  pain,  hemor- 
rhage, oedema,  exuberant  granulations,  phagedaena,  slough- 
ing, struma,  gout,  syphilis,  scurvy,  etc.  are  to  be  looked  upon 
as  complications.  The  leg  is  so  common  a  site  of  ulcers  as 
to  warrant  special  description. 


ULCERATION  AND   FISTULA.  IO3 

Acute  ulcer  of  the  leg  may  follow  an  acute  inflammation 
and  may  be  acute  from  the  start,  or  may  be  first  chronic  and 
become  acute.  It  is  characterized  by  rapid  progress  and 
intense  inflammation.  In  shape  these  ulcers  are  usually 
oval.  The  bottom  of  an  acute  ulcer  is  covered  with  a  mass 
of  gray  aplastic  l}-mph,  or  it  may  have  upon  it  large  green- 
ish sloughs.  The  edges  are  thin  and  undermined.  The  dis- 
charge is  very  profuse  and  ichorous,  excoriating  the  sur- 
rounding'parts.  The  adjacent  surface  is  inflamed  and  oedem- 
atous.  There  is  much  burning'  oain.  W^hen  the  ulcer 
spreads  with  great  rapidity  and  becomes  deeper  as  well  as 
larger  in  surface-area,  it  is  called  "  phagedaenic."  If  sloughs 
form,  this  indicates  that  tissue-death  is  going  on  so  rapidly 
that  the  dead  portions  have  not  time  to  break  down  and  be 
cast  off  Limited  stasis  produces  molecular  death  ;  more 
extensive  stasis,  a  slough.  Constitutionally,  there  is  gastro- 
intestinal derangement,  but  rarely  fever. 

Treatment. — In  treating  an  acute  ulcer  of  the  leg,  give  a 
dose  of  blue  mass  or  calomel,  followed  in  eight  or  ten^  hours 
by  a  saline  (.5ij  each  of  Rochelle  and  Epsom  salt).  Order 
light  diet.  Deny  stimulants  except  in  diphtheritic  ulcer. 
Administer  opium  if  pain  is  severe.  Use  a  spray  of  per- 
oxide and  the  scissors  and  forceps  to  get  rid  of  sloughs,  and 
after  their  removal  wash  the  ulcer  with  corrosive  sublimate. 
If  the  sloughs  cannot  be  removed,  use  the  antiseptic  poultice. 
After  asepticizing,  local  bleeding  is  of  great  value.  Tie  a 
fillet  below  the  knee,  make  multiple  punctures,  and  let  the 
patient  sit  with  his  leg  in  tepid  water  until  eight  or  ten 
ounces  of  blood  have  been  lost;  then  untie  the  fillet  and 
dress  with  antiseptic  poultices,  keeping  the  leg  elevated.  In 
two  days  paint  around  the  ulcer  with  equal  parts  of  tincture 
of  iodine  and  alcohol,  and  repeat  this  treatment  every  day, 
dressing  the  ulcer  with  iodoform,  covering  it  with  gauze,  and 
producing  pressure  by  means  of  a  roller. 


104  A   MANUAL    OF  SURGERY. 

Many  cases  do  very  well  on  the  local  use  of  lead-water 
and  laudanum  and  the  roller  after  bleeding.  If  the  discharge 
is  offensive,  use  gr.  iij  of  chloral  to  every  5J  of  lead-water. 
The  use  around  an  acute  ulcer  of  a  25  per  cent,  ointment 
of  ichthyol  is  highly  valuable.  If  sloughs  continue  to  form, 
touch  with  a  I  :  8  solution  of  acid  nitrate  of  mercury  or  with 
a  pure  solution  of  carbolic  acid  and  reapply  antiseptic  poul- 
tices. If  an  ulcer  continues  to  spread,  clean  it  up  with  per- 
oxide of  hydrogen,  dry  with  absorbent  cotton,  touch  with 
nitrate-of-mercury  solution  (i  :  8),  and  apply  a  poultice.  Do 
this  every  day  until  it  ceases  to  extend  and  granulations 
begin  to  form. 

In  an  ulcer  covered  with  a  great  mass  of  aplastic  lymph, 
touch  it  daily  with  solution  of  silver  nitrate  (gr.  xl  to  5J) 
or  with  acid  nitrate  of  mercury  (i  :  15)  and  dress  with  iodo- 
form and  gauze.  Give  internally  tonics,  stimulants,  and  good 
food.  In  any  case,  when  granulations  form  we  should  dress 
antiseptically  with  dry  dressings,  but  we  can  employ  a  non- 
irritant  ointment,  such  as  cosmoline.  If  granulation  is  slow, 
touch  every  day  with  a  solution  of  silver  nitrate  (gr.  x  to  ,lj) 
and  dress  antiseptically,  or  with  a  stimulating  ointment 
(resin  cerate  or  3J  of  ung.  hydrarg.  nitratis  to  3vij  of  ung. 
petrolii),  or  with  an  ointment  of  copper  sulphate,  gr.  iij  to  5J, 
or  with  3  drops  of  nitric  acid  to  5j  of  gum  Arabic  or  cotton. 

Chronic  ulcer  of  the  leg*  is  characterized  by  low  action  and 
slow  progress.  It  may  be  chronic  from  the  start,  or  it  may 
result  from  acute  ulcer.  More  usually  it  is  found  as  a  soli- 
tary ulcer  two  inches  above  the  internal  malleolus.  Syphi- 
litic ulcers  occur  in  a  group,  are  often  crescentic,  and  are  fre- 
quent upon  the  front  of  the  knee.  A  chronic  ulcer  is  circu- 
lar or  oval,  and  is  surrounded  by  congested,  discolored,  and 
indurated  skin,  this  induration  being  due  to  embryonic  tissue, 
and  there  is  often  eczema  or  a  brown  pigmentation  of  the 
neighboring  skin.     The  bottom  of  the  ulcer  is  uneven,  and 


ULCERATION  AND  FISTULA.  IO5 

usually  possesses  granulations  each  of  which  is  the  size  of 
a  pin-point,  red,  and  which  may  be  exuberant  or  may  be 
oedematous.  If  granulations  are  absent,  the  ulcer  has  the 
appearance  of  a  bit  of  liver.  The  edges  are  thick,  turned 
out,  and  not  sensitive  to  the  touch.  Occasionally  they  are 
thin  and  undermined.  Some  ulcers  are  thick,  indurated,  and 
adherent ;  this  prevents  healing  by  antagonizing  contraction. 

Trcatiucnt. — In  treating  a  chronic  ulcer,  give  a  saline  every 
day  or  so.  Treat  any  existing  diathesis.  Insist  on  rest  and, 
if  possible,  elevation.  Asepticize  the  ulcer.  Draw  blood  by 
shallow  scarifications  of  the  bottom  of  the  ulcer  and  the  skin. 
If  the  ulcer  is  adherent,  make  incisions  like  either  of  those 
shown  in  Figure  27,  each  cut  going  g 
through  the  deep  fascia.  These  incis-  \^^£^ 
ions,  besides  permitting  contraction,  ^  '^% 
allow  granulations  to  sprout  in  them,  \,  J  It 
which  eventuate  in  the  absorption  of  ^^^^^^^^^^^^^ 
the  exudate.  After  incision  keep  the  ^170^27.— indsio^  fcr'A^ 
part  elevated  and  dressed  antiseptically  ^^"^^"^  u''^^''- 
for  two  days.  In  two  days  after  scarification  or  incision, 
scrape  the  ulcer  with  a  curette  until  sound  tissue  is  reached, 
and  make  radiating  incisions  through  its  edge.  Use  anti- 
septic poultices  for  two  days  more,  then  paint  around  the 
ulcer  with  tincture  of  iodine  and  alcohol  (i  :  3)  and  dress  the 
leg  with  hot  lead-water  and  laudanum.  When  healing  begins, 
treat  as  outlined  for  healing  acute  ulcer  (p.  103). 

Comiplications. — Remove  by  scissors  and  forceps  any  use- 
less tissue.  Take  out  dead  bone  ;  slit  sinuses  ;  trim  over- 
hanging edges.  Treat  eczema  by  attention  to  the  bowels 
and  stomach,  and  locally  by  washing  with  Johnson's  ethereal 
soap  and  by  the  use  of  powdered  oxide  of  zinc  or  borated 
talcum,  the  ieg  being  wrapped  in  cotton.  Avoid  ordinary 
soap,  grease,  and  ointment.  Varicose  veins  demand  either 
ligation  in  several  points,  excision,  obliteration  with  Vienna 


I06  A   MANUAL    OF  SURGERY. 

paste,  or  the  continued  use  of  a  flannel  roller  or  a  Martin 
bandage.     Inflammation  is  met  by  rest,  elevation,  and  paint- 
ing the  neighboring  parts  with   dilute   iodine,  and   by  the 
use   of  a   hot   solution   of  lead-water   and    laudanum.     For 
calloused  edges  employ  radiating  incisions  or  cut  them  away. 
Ordinary  thick  edges  can  be  strapped.    In  strapping  use  adhe- 
sive plaster  and  do  not  completely  encircle  the  limb.    When 
the  parts  are  adherent,  completely  or  partly  surround  the  sore 
with  a  cut  through  the  deep  fascia.    If  the  bottom  of  the  ulcer 
is  foul,  dry  it  and  touch  with  a  solution  of  acid  nitrate  of 
mercury  (i  :  8)  or  with  a  solid  stick  of  silver  nitrate.     Repeat 
this  every  third  day  and  dress  with  an  antiseptic  poultice 
until  granulations  appear.     Superfluous  granulations  (proud 
flesh)  should  be  cut  away  or  mowed  down  with  silver  nitrate. 
When  a  man  having  an  ulcer  must  go  out,  use  a  firmly- 
applied  roller,  or,  better  still,  a  Martin  bandage.    This  bandage, 
which  is  made  of  red  rubber,  limits  the  amount  of  arterial 
blood  going  to  the  ulcer  and  favors  venous  flow  from  the 
sore  and  its  neighborhood.     The  bandage  should  be  used 
as  follows  :    Before  getting  out  of  bed,  spray  the  sore  with 
hydrogen  peroxide  by  means  of  an  atomizer,  dry  off  the 
froth  with  cotton,  wash  the  leg  with  soap  and  w^ater,  dry  it, 
and  put   on    the    bandage — all   of  which    should    be    done 
before  putting  a  foot  to  the  floor.     At  night,  after  getting  in 
bed,  take  off  the  bandage,  wash  with  soap  and  water,  and 
dry  it,  and  again  cleanse  the  leg  and  ulcer.     If  these  rules 
are  not  strictly  observed,  the  Martin  bandage  will  produce 
pain,  suppuration,  and  eczema  of  the  leg.     Irritable  ulcer  is 
due  to  exposure  of  a  nerve  and  destruction  of  its  sheath. 
Find  with  a  probe  the  painful  granulation  and  divide  it  with 
a  tenotome,  or  curette  the  ulcer  or  burn  it  with  solid  stick 
of  silver  nitrate.     If  healing  entirely  fails,  skin-graft.     There 
are  two   methods  of  skin-grafting — (i)    Reverdin's  and  (2) 
Thiersch's.     (See  Plastic  Surgery.) 


ULCERATION  AND  FISTULA.  10/ 

Ulcers  in  any  Region. —  Tlic  fungous  or  cxitberant  ulcer  is 
especially  common  in  burns  and  other  injuries  when  cica- 
tricial contraction  causes  venous  obstruction.  These  granu- 
lations bleed  when  touched.  Burn  or  cut  them  off  with  a 
sharp  knife,  stop  hemorrhage  if  there  be  any,  and  strap  or 
use  the  rubber  bandage. 

Erethistic,  irritable,  or  painful  ulcers,  which  are  very  sensi- 
tive, are  due  to  the  exposure  of  a  nerve-filament.  They  are 
especially  found  near  the  ankle,  over  the  tibia,  in  the  anus 
(fissure),  or  in  the  matrix  of  the  nail  (in  ingrowing  nail). 
Curette  an  erethistic  ulcer,  and  touch  with  pure  carbolic  acid 
or  with  the  solid  stick  of  silver.  Chloral,  gr.  xx  to  the 
ounce,  allays  the  pain;  so  does  cocaine  for  a  time. 

Pliagedcenic  Ulcer. — The  phagedsenic  ulcer,  which  means 
the  profound  microbic  infection  of  tissues  debilitated  by 
local  or  constitutional  disease,  is  commonly  venereal.  This 
ulcer  has  no  granulations  and  is  covered  with  sloughs  ;  its 
edges  are  thin  and  undermined,  and  it  spreads  rapidly  in 
all  directions.  It  requires  the  use  of  strong  caustics  or  the 
Paquelin  cautery  followed  by  iodoform  dressing.  Internally, 
use  tonics  and  stimulants. 

A  rodent  or  Jacob's  ulcer  is  a  superficial  epithelioma  devel- 
oping from  sebaceous  glands,  sweat-glands,  or  hair-follicles. 

Decubital  ulcer,  or  bed-sore,  is  due  to  pressure  upon  an  area 
of  feeble  circulation. 

Neuro-paralytic  or  trophic  nicer  is  due  to  impairment  of 
the  trophic  centres  in  the  cord. 

The  perforating  ulcer,  a  name  given  by  Vesigne,  commonl}' 
affects  the  metatarso-phalangeal  joint  or  the  pulp  of  the 
great  toe  about  a  corn.  The  parts  about  the  corn  inflame, 
and  pus  forms  which  runs  into  the  bone.  A  sinus  evacuates 
the  pus  b\*  the  side  of  the  corn.^  As  this  ulcer  may  be 
present   in   anesthetic   leprosy,  paralyzed   limbs,  and  tabes 

^  See  Treves  in  Lancet,  Nov,  29,  1884. 


I08  A    MANUAL    OF  SURGERY. 

dorsalis,  and  as  the  part  on  which  it  occurs  is  apt  to  be 
sweaty,  cold,  and  possessed  of  impaired  sensation,  and  as  the 
sore  may  be  hereditary,  it  is  usually  set  down  as  trophic 
in  origin.  Treatment  of  a  perforating  ulcer  consists,  accord- 
ing to  Treves,  in  going  to  bed  and  poulticing.  Every  time 
a  poultice  is  removed  the  raised  epithelium  around  the  ulcer 
is  cut  away  and  then  the  poultice  is  reapplied.  In  about 
two  weeks  an  ulcer  remains  surrounded  by  healthy  tissue. 
Treves  treats  this  sore  with  glycerin  made  to  a  creamy  con- 
sistency with  salicylic  acid  to  each  ounce  of  which  TTLx  of 
carbolic  acid  have  been  added.  He  directs  the  patient  to 
wear  during  the  rest  of  his  life  some  form  of  bunion-plaster 
to  keep  off  pressure.  If  in  a  perforating  ulcer  the  bone  is 
diseased,  it  must  be  removed.  This  ulcer  tends  to  recur  in 
the  same  spot  or  in  adjacent  parts,  and  it  may  be  necessary 
to  amputate  the  toe  or  the  foot. 

Epitheliomatous,  sarcomatous,  tuberculous,  and  syphilitic 
ulcers  are  considered  under  their  respective  heads. 

Fistula. — A  fistula  is  an  abnormal  communication  between 
the  surface  and  an  internal  part  of  the  body,  or  betv^een  two 
natural  cavities  or  canals.  The  first  form  is  seen  in  a  rectal 
fistula,  a  urethral  fistula,  or  a  biliary  fistula,  and  the  second 
form  is  seen  in  a  vesico-vaginal  fistula.  Fistulae  may  result 
from  congenital  defect,  as  when  there  is  failure  in  the  closure 
of  the  branchial  clefts,  sloughing,  traumatism,  and  suppura- 
tion. Fistulae  are  named  from  their  situation  and  communi- 
cations.    (Fig.  1 66). 

A  sinus  is  a  tortuous  track  opening  usually  upon  a  free 
surface  and  leading  down  into  the  cavity  of  an  imperfectly- 
healed  abscess.  A  sinus  may  be  an  unhealed  portion  of  a 
wound.  Many  sinuses  may  be  due  to  pus  burrowing  sub- 
cutaneously.  A  sinus  fails  to  heal  because  of  the  presence 
of  some  fluid  (as  saliva,  urine,  or  bile) ;  because  of  the 
existence  of  a  foreign  body,  as  dead  bone,  a  bit  of  wood, 


MORTIFICATION   OR    GANGRENE.  IO9 

a  bullet,  a  septic  ligature,  etc. ;  or  because  of  rigidity  of  the 
sinus-walls,  which  rigidity  will  not  permit  collapse.  The 
wallsof  a  tubercular  sinus  are  lined  with  a  material  identical 
with  the  pyogenic  membrane  of  a  cold  abscess.  Sinuses 
may  be  due  to  the  want  of  rest  (muscular  movements)  and 
to  general  ill-health. 

Trcatnioit. — In  treating  a  fistula  remove  any  foreign  body, 
lay  the  channel  open,  curette,  swab  with  pure  carbolic  acid, 
and  pack'  with  iodoform  gauze.  Fresh  air,  good  food,  and 
tonics  should  be  ordered. 


VII.    MORTIFICATION    OR    GANGRENE. 

Mortification  or  gangrene  is  death  in  mass  of  a  portion 
of  the  living  bod}' — the  dead  portions  being  visible — in  con- 
trast to  ulceration  or  molecular  death,  in  which  the  dead 
particles  are  too  small  to  be  seen  and  are  cast  away.  In 
gangrene  the  dead  portions  may  either  desiccate  or  putrefy. 
Gangrene  may  be  due  to  tissue-injury,  either  chemical  or 
mechanical,  to  failure  of  the  general  health,  to  circulatory 
impairment,  or  to  microbic  infection.  Molar  death  of  bone 
is  called  "  necrosis."  When  the  gangrened  portion  is  entirely 
dead,  the  process  is  spoken  of  as  "  sphacelus." 

Classification. — Gangrenes  are  divided  into  the  following 
three  great  groups  : 

(i)  Dry  gangrene,  which  is  due  to  circulator)-  interference, 
the  arterial  supply  being  decreased  or  cut  off  As  venous 
return  is  still  active,  all  fluid  is  taken  up  from  the  tissues, 
which  shrivel   up  and  mummify. 

(2)  Moist  gangrene,  which  is  due  to  interference  not  only 
with  arterial  ingress,  but  also  with  venous  return  oi'  capillary 
circulation,  the  dead  parts  remaining  moist. 

{3)  Septic  gangrene,  arising  from  virulent  septic  matter 
coming  from  outside. 


no  A   MANUAL    OF  SURGERY. 

There  are  many  gangrenous  processes  which  belong  under 
one  or  other  of  the  above  heads,  namely :  congenital  gan- 
grene, a  rare  form  existing  at  birth  ;  constitutional  gangrene, 
arising  from  a  constitutional  cause,  as  diabetes ;  cutaneous 
gangrene,  which  is  limited  to  skin  and  subcutaneous  tissue, 
as  in  phlegmonous  erysipelas ;  gaseous  or  enipJiscniatous 
"■anercne,  in  which  the  subcutaneous  tissues  are  filled  with 
putrefactive  gases  and  crackle  on  pressure ;  diabetic  or  gly- 
ccuniic,  due  to  diabetes ;  hospital  gangrene,  which  is  defined 
by  Foster  as  specific  serpiginous  necrosis,  the  tissues  being 
pulpefied :  some  consider  it  a  traumatic  diphtheria;  cold 
gangrene,  a  form  in  which  the  parts  are  entirely  dead 
(sphacelus) ;  hot  gangrene,  which  presents  some  inflamma- 
tion, as  shown  by  heat ;  idiopathic  gangrene,  which  has  no 
ascertainable  cause ;  mixed,  which  is  partly  dry  and  partly 
moist ;  primary,  in  which  the  death  of  the  part  is  direct,  as 
from  a  burn  ;  secondary,  which  follows  an  acute  inflamma- 
tion ;  multiple,  a  gangrenous  ecthyma ;  pressure,  which  is 
due  to  long  compression  ;  purpuric  or  scorbittic,  which  is  due 
to  scurvy  ;  Raynaud's  or  idiopathic  symmetrical,  which  is  due 
to  vascular  spasm  from  nerve-disorder ;  senile,  the  dry  gan- 
grene of  the  aged  ;  venous  or  static,  which  is  due  to  obstruc- 
tion of  circulation,  as  in  a  strangulated  hernia ;  trophic, 
which  is  due  to  nutritive  failure  by  reason  of  disorder  of 
the  trophic  nerves  or  centres;  thrombotic,  which,  is  due  to 
thrombus ;  embolic,  which  is  due  to  embolus ;  and  decubital 
gangrene,  from  bed-sores. 

Dry  or  chronic  g-angrene.  Pott's  g-angrene  (Fig.  28),  arises 
from  deficiency  of  arterial  blood.  In  a  person  with  healthy 
arteries  dry  gangrene  can  result  by  injury  of  the  main  trunk 
of  an  artery  (lodging  of  an  embolus,  ligation,  or  laceration). 
Gangrene  only  follows  injury  when  the  anastomatic  circu- 
lation fails  to  sustain  the  part.  When,  for  instance,  an  em- 
bolus lodges  and  causes  gangrene,  the  case  runs  the  following 


MORTIFICATION  OR    GANGRENE. 


Ill 


course:  Sudden  severe  pain  at  the  seat  of  impaction,  and 
also  tenderness;  pulsation  above,  but  not  below,  this  point; 
the  limb  below  the  obstruction  is  blanched,  cold,  and  an- 
aesthetic ;  within  forty-eight  hours,  as  a  rule,  the  gangrene 
has  mapped  out  its  area ;  the  limb  becomes  blue,  reddish, 
greenish,  and  then  black ;  the  skin  itself  becomes  shriveled 
and  its  outer  layer  stony  or  like  horn.  The  entire  part  may 
become  as  dry  as  a  mummy,  but  usually  there  are  spots 
where  some  fluid  remains,  and  these  spots  are  soft  and 
moist,  and  the  dead  tissue  where  it  joins  the  living  is  sure 
to  be  moist.     The  contact  of  dead  with  living  tissue  causes 


Fig.   28. — Chronic  Gangrene  of  the  Feet  (Gross). 


inflammation  in  the  latter  tissue,  a  bright-red  line  forms, 
and  we  have  exudation,  suppuration,  and  ulceration.  This 
line  of  ulceration  in  the  sound  tissues  is  called  the  "  line  of 
demarcation,"  it  being  Nature's  effort  at  amputation,  which 
in  time  may  get  rid  of  a  large  portion  of  a  limb,  and  then 
heal  as  any  other  ulcer. 

Senile  gangrene  is  a  form  of  dry  gangrene  due  to  feeble 
action  of  the  heart  plus  obliterating  endarteritis  or  atheroma 
of  peripheral  vessels.  The  vessels  do  not  properly  carry 
blood,  and  may  at  any  time  be  occluded  by  thrombosis. 
Senile  gangrene  most  often  occurs  in  the  toe  or  the  foot. 


112  A   MA A^ UAL    OF  SURGERY. 

Syinptouis. — A  man  whose  vessels  are  in  the  state  above 
indicated  is  generally  in  feeble  health  and  has  a  fatty  heart 
and  an  arciis  senilis  (a  red  or  white  line  of  fatty  degeneration 
around  the  cornea).  His  feet  feel  cold  and  numb,  and  they 
"go  to  sleep"  very  easily.  The  arteries  are  felt  as  rigid 
tubes  like  pipe-stems.  A  very  slight  injury  of  a  toe  will 
produce  extensive  inflammatory  stasis,  which  completely 
cuts  off  the  blood-supply  and  causes  gangrene  of  the  part. 
Gangrene  is  usually  announced  by  a  blue  spot,  followed  by 
a  vesicle  which  lets  out  bloody  serum  and  has  a  dry  floor. 
The  tissues  adjacent  to  the  dead  toe  become  victims  to  stasis 
and  gangrene,  and  the  process  ascends  until  it  reaches  tissue 
whose  circulation  is  sufficiently  good  to  permit  of  ulcera- 
tion instead  of  gangrene,  when  a  line  of  demarcation  forms. 
Before  the  line  of  demarcation  forms  there  is  some  burning 
pain ;  after  it  forms  pain  is  rarely  present.  If  embolism  in 
a  diseased  vessel  caused  the  gangrene,  the  pain  is  severe. 
In  senile  gangrene  the  periphery  is  always  dry,  the  part 
nearer  the  body  being  generally  somewhat  moist.  A  line 
of  demarcation  may  start,  but  prove  abortive,  the  tissue 
mortifying  above  it.  This  proves  that  tissue  near  the  line 
is  in  a  state  of  low  vitality.  An  entire  leg  can  die.  When 
a  limited  area  is  gangrenous,  constitutional  symptoms  are 
trivial  or  are  absent,  but  when  a  large  area  is  involved  we 
find  the  fever  of  septic  absorption.  Death  may  ensue  from 
exhaustion  caused  by  sleeplessness  and  pain,  from  septic 
infection,  or  from  embolism  of  internal  organs. 

Treatment  of  Senile  Gangrene. — When  injury  of  an  artery 
causes  us  to  fear  dry  gangrene,  the  patient  should  be  placed  in 
bed  and  the  part  relaxed,  massage  employed  from  time  to  time, 
and  the  part  be  kept  wrapped  up  in  cotton-wool  and  warmed 
wnih.  hot  bottles  or  water-bags.  If  gangrene  begins,  wait  for 
a  line  of  demarcation  and  amputate  well  above  it.  While 
vi^aiting  for  the  line  to  form,  dress  the  dead  part  antiseptically, 


MORTIFICATION  OR    GANGRENE.  II3 

induce  sleep,  and  give  good  food,  tonics,  and  stimulants. 
If  a  person  is  of  the  type  in  which  there  is  danger  of  senile 
gangrene,  he  should  be  cautioned  against  injuring  his  feet, 
especially  cutting  his  corns  carelessly,  which  is  highly  dan- 
gerous ;  any  wound,  however  slight,  requires  rest  and  anti- 
septic dressing.  He  must  wear  woollen  stockings,  put  a 
hot-water  bag  to  his  feet  on  cold  nights,  and  attend  to  his 
general  health.    A  little  whiskey  after  each  meal  is  indicated. 

When  gangrene  occurs,  if  it  shows  a  tendency  to  limit 
itself,  we  must  wait  for  a  line  of  demarcation  and  then 
amputate  high  up.  If  the  gangrene  shows  no  tendency 
to  limit  itself,  or  if  the  patient  develops  sepsis  or  exhaustion, 
at  once  amputate  high  up.  The  best  point  at  which  to 
amputate  is  above  the  knee,  so  that  the  deep  femoral,  which 
rarely  occludes,  will  nourish  the  flap.  Never  amputate  below 
the  tubercle  of  the  tibia.  Some  operators  disarticulate  at 
the  knee-joint.  Heidenhain  affirms  that  so  long  as  the  gan- 
grene is  limited  to  one  or  two  toes  we  should  merely  treat 
it  antiseptically,  elevate  the  limb,  and  wait  for  the  dead  part 
to  be  cast  off  spontaneously ;  if,  however,  it  extends  to  the 
dorsum  or  sole  of  the  foot,  amputate  at  once  above  the  knee. 
He  further  states  that  gangrene  of  the  flaps  almost  always 
occurs  in  amputation  below  the  knee,  and  high  amputation 
is  indicated  in  advancing  gangrene  with  or  without  fever.^ 

In  moist  or  acute  gangrene  (Fig.  29)  the  dead  part  remains 
moist  and  putrefies.  It  results  from  interference  with  venous 
return  or  capillary  flow,  as  well  as  from  arterial  ingress.  It 
is  seen  in  a  limb  after  ligature  or  destruction  of  its  main 
artery  and  vein,  after  long  constriction,  and  after  crushes  and 
lacerated  wounds.  Moist  gangrene  may  follow  acute  inflam- 
mation, or  may  be  due  to  local  constriction  (strangulated 
hernia),  crusliing,  chemical  irritants,  heat,  and  cold. 

Moist  gangrene  of  a  limb  is  seen  typically  when  both  vein 

^Deutsche  medicinische    Wochenschrift,   1 89 1,  p.  1087. 
8 


114  A   MANUAL    OF  SURGERY. 

and  artery  are  tied.  The  leg  swells  and  is  pulseless,  the 
skin  becomes  cold  and  livid,  and  is  raised  up  into  blebs 
which  contain  sero-  sanguineous  fluid.  The  extremity  swells 
enormously,  there  is  pain  at  the  seat  of  obstruction,  and 
septic  symptoms  quickly  develop.  The  bullae  break  and 
disclose  the  deeper  structures,  which  are  swollen  and  oedem- 
atous.  The  foetor  is  horrible.  Portions  of  the  extremity 
become  emphysematous.    A  line  of  demarcation  soon  forms. 


Fig.  29. — Acute  Mortification  (Gross). 

Moist  g-angrene  from  inflammation  is  due  to  pressure 
of  the  exudate  cutting  off  the  blood-supply.  It  occurs  in 
phlegmonous  erysipelas.  When  an  inflammation  is  about 
to  terminate  in  gangrene,  all  the  signs  of  inflammation,  local 
and  constitutional,  increase;  when  gangrene  occurs,  they 
cease,  bullae  appear,  emphysema  is  noted,  with  great  swell- 
ing and  all  the  other  symptoms. 

Treatment  of  Moist  Gangrene. — In  moist  gangrene  of  a 
limb  we  should  wait  for  a  line  of  demarcation  and  then 
amputate  clear  of  and  above  it.  Dress  the  dead  parts  anti- 
septically  while  waiting.  Give  opium,  tonics,  good  food,  and 
stimulants.  In  inflammatory  gangrene  relieve  tension  by 
incisions  and  then  cut  away  the  dead  parts.  Stimulate  freely 
and  feed  well. 

Septic  gangrene  is  divided  into — (i)  traumatic  spreading 
gangrene  ;  (2)  hospital  gangrene ;  (3)  phagedaena ;  (4)  noma 
vulvae ;  and  (5)  cancrum  oris. 


MORTIFICATION   OR    GANGRENE.  II5 

Traumatic  spreading  gangrene  results  from  a  virulent 
infection  of  a  severe  wound.  It  is  commonest  after  com- 
pound fractures,  and  begins  within  forty-eight  hours  after 
the  accident.  It  does  not  begin  at  the  periphery,  as  does 
ordinary  traumatic  moist  gangrene,  but  at  the  wound-edges, 
which  turn  red,  green,  and  finally  black.  The  entire  limb 
swells  from  oedema,  the  skin  peels  away,  and  emphysema 
sets  in.  The  gangrene  spreads  up  and  down  from  the 
wound,  and  in  thirty-six  hours  may  involve  an  entire  limb. 
No  line  of  demarcation  forms.  The  system  is  soon  over- 
whelmed with  ptomaines,  and  the  patient  has  septic  intoxi- 
cation, or  he  passes  into  profound  collapse  with  subnormal 
temperature. 

Treatment. — In  treating  traumatic  spreading  gangrene  a 
line  of  demarcation  need  not  be  waited  for,  as  none  can  form. 
Amputation  should  at  once  be  performed  high  up  and  stimu- 
lants must  literally  be  poured  into  the  patient. 

Hospital  gangrene  or  sloughing  phagedaena  is  a  disease 
that  has  practically  disappeared  from  civilized  communities. 
It  formerly  occurred  in  crowded,  ill-ventilated  hospitals. 
Some  consider  it  traumatic  diphtheria.  Koch  thinks  it  is 
due  to  streptococci.  Jonathan  Hutchinson  says,  "  Hospital 
gangrene  is  set  up  by  admitting  to  the  wards  a  case  of 
syphilitic  phagedaena."  It  may  show  itself  as  a  diphtheritic 
condition  of  a  wound,  as  a  process  in  which  form  sloughs 
like  masses  of  tow,  or  as  a  phagedsenic  ulceration.  The 
surrounding  parts  are  inflamed  and  painful,  and  buboes  form 
in  adjacent  lymphatic  glands.  The  system  passes  into  a  low 
septic  state. 

Treatment. — In  treating  hospital  gangrene  ether  should  be 
given,  the  large  sloughs  removed  with  scissors  and  forceps, 
the  part  dried  with  cotton  and  cauterized  with  bromine.  Take 
a  tumblerful  of  water  and  into  it  pour  the  bromine  :  this  falls 
to  the  bottom ;  draw  it  up  with  a  syringe  and  inject  it  into 


Il6  A   MANUAL    OF  SURGERY. 

the  depths  of  the  wound.  Iodoform  should  be  "shovelled" 
on  and  antiseptic  poultices  be  used  until  the  sloughs  separate, 
when  the  sore  is  treated  as  an  ordinary  ulcer.  If  a  limb  is 
hopelessly  damaged  by  this  form  of  gangrene,  we  must  wait 
for  a  line  of  demarcation  and  amputate. 

Special  Forms  of  Gangrene. — Symmetrical  or  Raynaud's 
gangrene  arises  in  severe  cases  of  Raynaud's  disease.  It  is 
a  dry  gangrene.  Raynaud's  disease,  a  vaso-motor  neurosis 
seen  in  children  and  young  adults,  is  characterized  by  attacks 
of  cold,  dead  bloodlessness  in  the  fingers  or  toes  as  a  result 
of  exposure  to  cold  or  of  emotional  excitement  (local  syn- 
cope). In  the  more  severe  cases  we  may  have  capillary 
congestion  and  livid  swelling  (local  asphyxia).  Chilblains 
belong  in  this  group.  The  patient  complains  of  pain,  ting- 
ling, and  stiffness.  It  is  after  local  asphyxia  that  the  gan- 
grene may  appear. 

This  gangrene  is  usually  seen  upon  the  ends  of  the  fingers 
or  the  toes,  but  it  may  attack  the  lobes  of  the  ears,  the  tip  of 
the  nose,  or  the  skin  of  the  arms  or  the  legs.  When  gan- 
grene is  about  to  occur,  the  local  asphyxia  at  that  point 
deepens,  anaesthesia  is  complete,  and  the  part  blackens  and 
becomes  cold..  The  epidermis  is  now  raised  up  into  blebs, 
which  rupture  and  expose  dry  surfaces.  A  line  of  demarca- 
tion forms,  and  the  necrosed  area  is  removed  as  a  slough. 
Widespread  gangrene  from  Raynaud's  disease  is  rare ;  there 
is  not  often  involved  a  large  area — only  a  small  superficial 
portion.  Sometimes  the  disease  is  seen  upon  the  trunk. 
These  attacks  recur  again  and  again,  are  often  accompanied 
by  haemoglobinuria  (Osier),  and  are  sometimes  excited  by 
cold  or  by  mental  disturbance.  The  pathology  is  uncertain. 
Local  syncope  is  thought  to  be  due  to  vascular  spasm,  and 
local  asphyxia  to  some  contraction  of  the  arterioles  with 
dilatation  of  the  capillaries  and  venules. 

Treatment  of  Raynaud's  Disease. — When  attacks  of  Ray- 


MORTIFICATION  OR    GANGRENE.  11/ 

naud's  disease  are  so  severe  as  to  threaten  gangrene,  the 
patient  should  be  put  to  bed  ;  if  the  feet  are  affected,  elevate 
the  legs,  wrap  the  extremity  in  cotton-wool,  and  apply  heat. 
If  the  hands  are  affected,  they  should  be  elevated,  wrapped 
up,  and  the  arm  and  hand  be  warmed.  Massage  is  useful. 
When  gangrene  occurs,  dress  the  part  antiseptically  until  a 
line  of  demarcation  forms,  and  then  dispose  of  the  dead  parts 
by  scissors,  forceps,  and  antiseptic  poultices.  If  amputation 
becomes  necessary,  which  will  rarely  be  the  case,  wait  for 
a  line  of  demarcation. 

Diabetic  gangrene  resembles  in  many  points  senile  gan- 
grene, but  the  dead  portions  remain  somewhat  moist  and 
putrefy.  Diabetic  gangrene  is  most  usually  met  with  upon  the 
feet  and  legs,  but  it  may  attack  the  genital  organs,  thigh,  lung, 
buttock,  eye,  back,  finger,  or  neck  (Hunt).  It  may  begin  in 
a  perforating  ulcer,  or,  as  in  senile  gangrene,  a  trivial  injury 
is  apt  to  be  the  exciting  cause.  It  spreads  slowly,  but  more 
rapidly  than  senile  gangrene.  There  is  little  tendency  to  the 
formation  of  any  line  of  demarcation.  Surgeons  have  become 
shy  of  amputating  in  such  cases,  but  the  experience  of  Kuster 
of  Berlin  proves  conclusively  that  an  amputation  should  be 
performed  at  once  in  diabetic  gangrene,  and  should  be  done 
above  the  knee.  If  we  operate  below  the  knee,  the  flaps 
will  become  gangrenous.  It  has  been  noted  that  sugar  will 
sometimes  disappear  from  the  urine  after  an  amputation. 
Of  eleven  amputations  by  Kuster,  six  recovered  and  five 
died ;  and  of  these  five,  three  had  albumin  in  the  urine  as 
well  as  sugar.^ 

Gangrene  from  ergotism  is  a  peripheral  dr\^  gangrene 
arising  from  tonic  vascular  contraction  produced  by  the  ergot 
in  bread  made  from  diseased  rye.  The  gangrene  is  preceded 
by  anaesthesia,  muscular  cramp,  tingling  pains,  itching,  and 

^  See  the  convincing  article  of  Chas.  A.  Powers  in  Amer.  Journal  of  Med. 
Sciences,   nth  Nov.,   1892. 


Il8  A   MANUAL    OF  SURGERY. 

"  gradual  blood-stasis  in  certain  vascular  areas "  (Osier). 
This  form  of  gangrene  occurs  in  epidemics  where  rye-bread 
is  largely  used,  but  is  very  rare  in  the  United  States.  It 
usually  affects  the  fingers  or  toes,  but  may  involve  an  entire 
limb.  In  acute  cases  death  occurs  in  from  seven  to  ten 
days.^  In  chronic  cases  await  a  line  of  demarcation  and  then 
amputate. 

Gangrene  from  Frost-bite. — When  parts  have  been  badly 
frozen,  the  peripheral  parts  dry  up,  being  deprived  of  all 
blood  because  of  contraction  of  the  vessels.  When  a  patient 
so  afflicted  is  brought  into  a  warm  atmosphere,  blood  cannot 
run  into  the  dead  part,  and  the  living  tissues  in  contact  with 
it  inflame,  forming  a  line  of  demarcation.  Hence  we  note 
that  severe  frost-bite  causes  dry  gangrene.  If  a  part  which 
is  not  so  badly  frozen  is  brought  suddenly  into  a  warm 
atmosphere,  inflammation  takes  place  when  the  blood  runs 
into  the  deadened  tissues,  and  moist  gangrene  results.  A 
frost-bite  in  which  the  skin  is  livid  and  not  as  yet  gangrenous 
should  be  treated  by  frictions  with  snow  or  towels  soaked 
in  iced  water.  As  the  skin  becomes  warmer  and  congestion 
disappears  the  part  should  be  wrapped  up  in  cotton-wool. 
A  sufferer  from  frost-bite  should  not  suddenly  be  brought  into 
a  warm  room.  When  the  parts  are  dead  or  when  gangrene 
follows,  if  only  small  areas  be  involved,  allow  the  dead  part 
to  come  away  spontaneously,  wrapping  it  up  in  the  mean 
while  with  antiseptics ;  if  removal  be  delayed  by  cartilage, 
ligament,  or  bone,  cut  through  the  retaining  structure. 
If  amputation  is  necessary,  await  a  line  of  demarcation,  as 
we  are  not  sure  how  high  tissue-damage  extends,  and  to 
amputate  through  devitalized  parts  would  mean  renewed 
gangrene. 

Noma,  or  cancrum  oris,  is  a  gangrene  beginning  as  a 
sloughing  ulcer  on  the  gums  or  cheeks,  and  affecting  young 

'  Pick,  in  Heath's  Surgical  Dictionary. 


MORTIFICATION  OR    GANGRENE.  I  I9 

children  who  Hve  amid  filth  and  squalor  or  who  are  conva- 
lescing from  acute  fevers.  This  disease  may  destroy  large 
portions  of  the  cheeks  and  jaws.  The  constitutional  symp- 
toms are  diarrhoea,  fever,  and  great  exhaustion.  Death  is 
the  usual  result,  due  frequently  to  septic  broncho-pneumonia 
(Bowlby).  Lingard  has  found  a  bacillus  which  he  believes 
is  causative  of  noma. 

The  treatment  of  noma  consists  in  destruction  of  the  dis- 
eased tissue  by  nitric  acid  or  the  cautery,  the  use,  locally 
and  often,  of  peroxide  of  hydrogen  and  antiseptic  washes, 
and,  internally,  the  employment  of  good  food,  stimulants, 
and  tonics. 

Sloug-hing-  is  a  process  of  ulceration  by  which  visible  por- 
tions of  dead  tissue  are  separated.  These  visible  portions 
are  called  "  sloughs  ; "  if  they  were  large  they  would  be 
called  "  gangrenous  masses."  A  large  slough  is  a  gangre- 
nous mass  ;  a  small  gangrenous  mass  is  a  slough ;  there  is 
no  difference  in  the  process,  which  corresponds  to  the  forma- 
tion of  a  line  of  demarcation.  Sloughing  requires  thorough 
cleansing,  removal  of  the  sloughs,  and  antiseptic  treatment. 

Phag-edsena  is  a  process  (most  common  in  a  venereal  sore) 
in  which  the  surrounding  tissues  are  rapidly  eaten  up,  the 
sore  becoming  jagged  and  irregular,  with  a  sloughy  base 
and  thin  edges  ;  the  discharge  is  thin  and  reddish,  and  the 
encircling  tissues  are  deeply  congested.  This  ulcer  has  no 
tendency  to  heal.  It  is  due  to  a  specific  poison  which  is  not 
yet  isolated.  Noma  vuIvce  is  a  form  of  phagedaena  which 
attacks  the  genitals  of  little  girls  who  are  unhealthy,  dirty, 
or  convalescent  from  a  specific  fever. 

The  treatment  of  phagedcBiia  consists  in  repeated  touching 
with  tincture  of  chloride  of  iron  and  the  local  use  of  iodo- 
form, the  employment  of  continued  irrigation,  or  the  appli- 
cation of  the  cautery,  chemical  or  actual.  Whatever  else  is 
done,  tonics,  stimulants,  and  nutritious  diet  must  be  given. 


120  A   MANUAL    OF  SURGERY. 

Decubital  Gangrene  or  Bed-sore ;  Decubitus. — A  bed- 
sore is  the  result  of  local  failure  of  nutrition  in  a  person  whose 
tissues  are  in  a  state  of  low  vitality  from  disease  or  from 
injury.  Such  sores  are  due  to  pressure,  aided  by  the  presence 
of  urine,  of  faeces,  and  of  sweat,  to  wrinkling  of  the  sheets, 
or  to  the  dropping  of  foreign  bodies  (such  as  crumbs)  in  the 
bed.  These  ordinary  pressure-sores  arise  like  splint-sores 
due  to  the  pressure  of  a  splint  upon  the  tissues  over  a  bony 
prominence.  They  occur  over  the  heels,  elbows,  scapulae, 
trochanters,  sacrum,  and  nuchae.  The  pressure  interferes 
with  the  blood-supply,  the  weakened  tissues  inflame,  vesica- 
tion occurs,  sloughs  form,  and  an  ugly  ulcer  is  exposed. 

The  acute  bed-sore  of  Charcot  is  seen  during  certain  dis- 
eases and  after  some  injuries  of  the  nervous  system.  These 
sores  are  usual  over  the  sacrum  in  acute  myelitis,  and  may 
appear  in  four  or  five  days  after  the  beginning  of  a  disease 
or  the  infliction  of  an  injury.  The  surgeon  sees  acute  bed- 
sores upon  the  buttock  of  the  paralyzed  side  after  brain- 
injuries,  and  over  the  sacrum  in  spinal  injuries.  Some  believe 
these  sores  are  due  to  vaso-motor  disorder,  but  others, 
notably  Charcot,  attribute  them  to  disturbance  of  the  trophic 
nerves  or  centres. 

Ti'catincnt  of  Bed-sores. — The  "ounce  of  prevention"  is 
here  invaluable.  From  time  to  time,  if  possible,  alter  the 
position  of  the  patient,  keep  him  clean,  maintain  the  blood- 
distribution  of  the  skin  by  frequent  rubbing  with  alcohol 
and  a  towel,  and  keep  the  sheet  clean  and  smooth.  When 
congestion  appears  (paratrimma,  or  beginning  sore),  at  once 
use  an  air-cushion  or  a  w^ater-bed  and  redouble  the  care  to 
frequently  change  the  position  of  the  patient.  Not  only 
protect,  but  also  harden,  the  skin.  Wash  the  part  twice 
daily  and  apply  spirits  of  camphor  or  glycerole  of  tannin ; 
or  rub  with  salt  and  whiskey  (^ij  to  Oj) ;  or  apply  a  mixture 
of  5SS  of  powdered  alum,  f^ij   of  tincture  of  camphor,  and 


MORTIFICATION  OR    GANGRENE.  121 

the  whites  of  four  eggs ;  or  paint  with  corrosive  subhmate 
and  alcohol  (gr.  ij  to  5J) ;  or  apply  tannate  of  lead  or  equal 
parts  of  oil  of  copaiba  and  castor  oil ;  or  paint  on  a  protective 
coat  of  flexible  collodion. 

When  the  skin  seems  on  the  verge  of  breaking,  paint  it 
with  a  solution  of  nitrate  of  silver  (gr.  xx  to  5J).  When 
the  skin  breaks,  a  good  plan  of  treatment  is  to  touch  once 
a  day  with  silver  solution  (gr.  x  to  the  ounce)  and  cover 
with  zinc-ichthyol  gelatin.  We  can  wash  the  sores  daily  with 
I  :  2000  corrosive-sublimate  solution,  dust  with  iodoform,  and 
cover  with  soap  plaster,  with  lint  spread  with  zinc  ointment, 
or  with  dry  aseptic  gauze.  When  sloughs  form,  cut  most 
of  them  off  with  scissors  after  cleaning  the  parts.  Slit  up 
sinuses.  Use  antiseptic  poultices.  In  sloughing  Dupuytren 
employs  pieces  of  lint  wet  with  lime-juice  and  dusted  with 
cinchona  and  charcoal.  In  obstinate  cases  use  the  continu- 
ous hot  bath  or  the  intermittent  ice  poultice.  When  the 
sloughs  separate,  dress  antiseptically  or  with  equal  parts  of 
resin  cerate  and  balsam  of  Peru.  If  healing  is  slow,  touch 
occasionally  with  silver  solution  (gr.  x  to  ^j).  Bed-sores, 
being  expressiv^e  of  lowered  vitality,  demand  that  the  patient 
shall  be  stimulated,  shall  be  well  nourished,  and  shall  have 
good  sleep. 

Rules  "when  to  Amputate  for  Gangrene. — In  dry  gan- 
grene, due  to  embolus  in  a  healthy  arter}',  wait  for  a  line  of 
demarcation.  In  senile  gangrene,  if  it  affect  only  one  or  two 
toes,  let  the  dead  parts  be  cast  off  spontaneously.  If  a  greater 
area  is  invoK^ed  or  the  process  spreads,  amputate  above  the 
knee  without  waiting  for  the  line.  In  oreiiuary  moist  gan- 
grene wait  for  a  line  of  demarcation.  In  traumatic  spreading 
gangrene  amputate  at  once.  In  hospital  gangrene  and  in 
Raynaud's  gangrene  wait  for  a  line  of  demarcation.  In 
diabetic  gangrene  amputate  at  once,  high  up.  In  ergot  gan- 
grene and  in  fj'ost  gangrene  wait  for  a  line  of  demarcation. 


122  A   MANUAL    OF  SURGERY. 

VIII.  THROMBOSIS   AND    EMBOLISM. 

Thrombosis  is  the  coagulation  of  blood  in  a  vessel,  which 
blood-clot  remains  at  its  point  of  .origin  and  plugs  up  the 
vessel  partially  or  completely.  This  process  is  an  essential 
part  in  the  arrest  of  hemorrhage;  it  occurs  in  phlebitis,  and 
affords  a  frequent  basis  for  embolism.  We  find  thrombi  in 
the  veins,  in  arteries,  and  in  the  heart.  Clotting  is  due  to 
destruction  of  white  blood-cells,  a  ferment  being  set  free 
causing  the  union  of  the  normal  blood-albuminoids,  fibrino- 
gen and  fibrinoplastin.     Figure  3  (PL  2)  shows  a  throm.bosis. 

Causes  of  Thrombus. — Retarded  circulation  is  a  cause  in 
consumption,  influenza,  and  fevers,  the  blood  clotting  behind 
the  vein-valves.  The  pressure  of  a  bandage  or  of  a  splint  or 
the  presence  of  varicose  veins  may  cause  thrombosis.  Liga- 
tion also  causes  it.  It  may  be  produced  by  injuries  of  a  ves- 
sel ;  by  foreign  bodies  in  a  vessel ;  by  atheroma  in  arteries  ; 
by  sutures  in  a  vessel ;  by  certain  diseases,  such  as  gout,  ty- 
phoid fever,  pregnancy,  and  septic  processes ;  by  phlebitis 
or  arteritis  arising  in  the  vessel  or  from  extension  of  sur- 
rounding inflammation ;  and  by  entrance  of  specific  organisms. 

It  has  been  asserted  that  so  long  as  the  endothelium  of  a 
vessel  is  uninjured  a  clot  does  not  form.  Slowing  of  the 
blood-current  in  aseptic  conditions,  it  is  now  taught,  will  not 
cause  thrombosis.  When  moving  blood  coagulates,  the  third 
corpuscles  first  settle  out,  and  then  the  leucocytes.  This  is 
known  as  the  white  or  "  ante-mortem  "  thrombus — the  clot 
of  moving  blood.  Thrombi  from  moving  blood  are  rarely 
pure  white  :  they  contain  some  red  corpuscles,  forming  mixed 
thrombi.  The  red  thrombus  plugs  vessels  which  are  cut 
across  or  ligated ;  it  occurs  in  septic  processes,  and  takes 
place  after  death.  A  thrombus  may  be  absorbed,  first  embry- 
onic tissue  and  then  fibrous  tissue  replacing  it  (organization). 
A  thrombus  may  degenerate  and  break  down  (fatty  degen- 


THROMBOSIS  AND  EMBOLISM.  1 23 

eration),  giving  rise  to  emboli.  A  thrombus  may  undergo 
purulent  liquefaction,  infective  emboli  being  set  free. 

Symptoms. — The  symptoms  are  dependent  on  the  seat  of 
the  obstruction.  An  organ  or  a  part  of  an  organ  may 
exhibit  functional  aberration.  The  local  signs  in  a  vessel 
accessible  to  touch  or  sight  are  the  presence  of  a  clot,  and, 
if  it  be  an  artery,  anaemia  and  the  absence  of  pulse  below  it ; 
if  it  be  a  v;ein,  swelling  and  oedema.  There  are  usually  pain 
and  anaesthesia. 

Treatment. — If  in  a  limb,  raise  the  limb,  keep  it  perfectly 
quiet  to  avoid  detachment  of  fragments  (emboli),  apply  a 
bandage  and  heat,  and  paint  with  iodine  or  rub  with  ichthyol. 
The  great  danger  is  the  formation  of  emboli,  so  avoid  move- 
ments and  rough  handling. 

Embolism  signifies  vascular  plugging  by  a  foreign  body 
(usually  a  blood-clot)  which  has  been  brought  from  a  dis- 
tance. Emboli  may  arise  either  in  the  venous  or  in  the 
arterial  system,  but  lodge  in  an  artery  or  in  the  veins  of  the 
liver.  The  initial  thrombus  may  form  upon  diseased  heart- 
valves  or  in  a  vein.  It  may  be  composed  of  fat,  micro- 
organisms, air,  or  a  portion  of  a  tumor.  An  embolus  is 
arrested  when  it  reaches  a  vessel  whose  diameter  is  less  than 
its  own.  It  is  usually  caught  just  above  a  bifurcation.  When 
an  embolus  lodges,  it  at  once  partially  or  entirely  obstructs 
the  circulation,  and  increases  in  size  by  thrombosis.  A  non- 
septic  embolus  usually  organizes.  A  soft  embolus  may  dis- 
integrate and  permit  of  re-establishment  of  the  circulation. 
An  embolus  may  cause  an  aneurysm.  A  septic  embolus 
breaks  down,  forms  a  metastatic  abscess,  and  sends  other 
emboli  onward.     Figure  2  (PL  2)  shows  an  impacted  embolus. 

An  embolus  is  more  serious  than  a  thrombus  :  it  causes 
sudden  plugging  which  makes  serious  anaemia  inevitable, 
and  it  may  produce  gangrene  if  the  collateral  circulation 
fails.     In  organs  with  terminal  arteries  (spleen,  kidney,  brain, 


124  ^    MANUAL    OF  SURGERY. 

and  lung)  there  is  no  collateral  circulation  if  embolism  causes 
infarction.  The  embolus  produces  an  area  of  anaemia ;  the 
removal  of  all  propulsion  upon  the  venous  blood  causes  it 
to  flow  back  and  stagnate,  and  vascular  elements  exude, 
forming  a  wedge-shaped  area  of  red  tissue,  the  embolus 
being  the  apex  of  the  wedge.  This  is  known  as  the  "  red 
infarction,"  and  is  often  seen  in  the  lung.  The  white  infarc- 
tion seen  in  the  brain  and  kidney  is  not  due  to  retrogression 
of  venous  blood,  but  is  due  to  anaemia  and  resulting  coagu- 
lation necrosis. 

Symptoms. — The  symptoms  depend  upon  the  organ  in- 
volved. They  are  sudden  in  onset,  and  consist  of  loss  of 
function  which  is  permanent  or  is  followed  by  inflammation 
or  softening.  Embolism  of  the  cerebral  arteries  may  cause 
aphasia,  paralysis,  or  coma.  Embolism  of  the  pulmonary 
artery  may  cause  almost  instant  death.  Embolism  of  the 
central  artery  of  the  retina  causes  blindness.  Embolism  of 
a  large  artery  of  a  limb  produces  symptoms  identical  with 
thrombus,  except  more  sudden  and  decided. 

Treatment. — The  treatment  depends  upon  the  part  involved. 
In  a  limb,  rest,  elevate,  and  keep  it  warm  in  order  to  stimu- 
late the  collateral  circulation.  If  gangrene  ensues,  await  a 
line  of  demarcation  and  amputate.  After  an  operation  upon 
veins  (as  in  varicocele),  after  a  cutting  operation,  and  after 
fracture,  avoid  as  much  as  possible  movements  or  handling, 
as  fragments  of  thrombus  may  be  detached. 

Fat-embolism  is  an  accumulation  in  the  capillaries  of  liquid 
fat,  arising  after  injuries  of  adipose  tissue,  when  we  have 
high  tension  to  force  the  fat  into  the  open  mouths  of 
veins.  Some  fat  may  get  into  the  blood  by  means  o'i  the 
lymphatics.  Fat-embolism  occurs  in  osteo-myelitis,  after 
extensive  bruises,  crushes,  or  lacerations,  and  after  amputa- 
tions, fractures,  resections,  or    rupture  of  the    liver.^     This 

1  G.  H.  Makins,  in  Heath's  Didionaryf. 


SEPTICEMIA   AND   PYEMIA.  1 25 

fluid  fat  accumulates  especially  in  the  capillaries  of  the  lung 
and  brain. 

Symptoms. — The  symptoms  are  those  of  oedema  of  the 
lungs  and  exhaustion,  often  with  com^i  or  delirium.  There 
are  restlessness,  dyspnoea,  rapid  pulse  and  respiration.  If 
life  is  prolonged  a  day  or  two,  oil  is  found  in  the  urine. 
These  symptoms  never  occur  until  at  least  twenty-four  hours 
after  the  accident,  and  rarely  before  the  third  day.  The 
symptoms  occur  at  a  later  period  than  those  of  shock,  and 
at  an  earlier  period  than  those  of  ordinary  embolism  of  the 
lung.  Severe  cases  are  commonly  fatal ;  milder  cases  are 
often  recovered  from. 

Treatment. — The  treatment  consists  of  the  ordinary  meth- 
ods used  in  shock — stimulants,  heat,  etc.,  with  dry  cupping 
of  the  chest,  diuretics,  strychnine,  and,  it  may  be,  artificial 
respiration.  See  that  drainage  of  the  wound,  if  an  external 
wound  exists,  is  good,  and  thoroughly  immobilize  the  dam- 
aged part. 


IX.   SEPTICEMIA   AND    PYEMIA. 

Septicsemia,  or  sepsis,  is  a  febrile  malady  due  to  the  intro- 
duction into  the  blood  of  septic  organisms  or  their  products. 
There  is  no  one  special  causative  organism,  and  any  microbe 
which  produces  inflammatory  and  febrile  products  can  cause 
it.  Either  streptococci  or  staphylococci  are  present.  It  arises 
by  absorption  of  septic  matter.  Clinically  we  make  two  forms 
of  septicaemia:  (i)  sapraemia,  septic  or  putrid  intoxication; 
and  (2)  septic  infection,  true  or  progressive  septicaemia. 

Sapraemia,  or  septic  intoxication,  is  due  to  the  absorption 
of  poisonous  ptomaines  from  a  putrefying  area.  The  bacteria 
do  not  enter  the  blood,  but  their  toxines  do,  and,  as  these 
toxines  are  alkaloids,  the  condition  is  comparable  to  poison- 
ing by  successive  alkaloidal   injections,  the  symptoms  and 


126  A   MANUAL    OF  SURGERY. 

prognosis  depending  upon  the  dose.  Slight  symptoms  and 
recovery  follow  a  small  dose ;  grave  symptoms  and  death 
follow  a  large  one.  The  poison  does  not  multiply  in  the 
blood,  and  a  drop  of  the  blood  of  a  person  laboring  under 
putrid  intoxication  will  not  produce  the  disease  when  intro- 
duced into  the  blood  of  a  well  person  ;  in  other  words,  the 
disease  is  not  infective.  Sapraemia  results  from  the  absorp- 
tion of  putrid  matter  from  considerable  areas  which  are  under 
high  pressure.  It  may  follow  labor  where  putrid  fluid  is 
retained  in  the  womb,  or  follow  amputation  where  pus  is  pent 
up  within  the  flaps.  In  this  condition  there  always  exist 
a  considerable  absorbing  surface  and  a  large  amount  of  dead 
matter  which  has  become  putrid. 

Symptoms. — In  twenty-four  hours  or  more  after  the  deliv- 
ery of  a  baby,  after  an  injury,  or  after  an  operation  there  is 
a  severe  chill  followed  by  high  temperature,  gastric  dis- 
turbance, dry  tongue,  weak  rapid  pulse,  great  prostration, 
muscular  twitching,  restlessness,  headache,  often  delirium, 
diarrhoea,  drying  up  of  wound-discharge,  diminution  or  sup- 
pression of  urine,  and  a  strong  tendency  to  congestion  of  vari- 
ous organs.     Great  elevation  of  temperature  precedes  death. 

Treatment. — The  treatment  is  to  at  once  drain  and  asep- 
ticize the  putrid  area  and  give  enormous  doses  of  alcohol. 
Strychnine  and  digitalis  are  useful.  Establish  the  action  of 
the  skin  and  kidneys  ;  allay  vomiting  by  champagne,  cracked 
ice,  calomel,  cocaine,  or  carbolic  acid  with  bismuth.  Give 
food  every  three  hours.  Feed  on  milk,  milk  and  lime-water, 
liquid  beef-peptonoids,  and  other  concentrated  foods.  Use 
quinine  in  stimulant  doses.  Antipyretics  are  useless.  Watch 
out  for  any  visceral  congestion,  and  treat  it  at  once. 

Septic  infection,  or  true  septicaemia,  is  a  true  infective 
process.  Intoxication  exists,  due  in  part  to  toxines  introduced 
from  the  infected  area,  and  also  to  toxines  evolved  by  bac- 
teria which  have  been  taken  into  the  blood.     In  sapraemia 


SEPTICEMIA   AND  PYEMIA.  12/ 

the  blood  contains  toxines,  but  not  organisms.  In  septic 
infection  the  blood  contains  both  toxines  and  organisms,  the 
bacteria  multiplying  in  it.  The  symptoms  of  sapraemia  de- 
pend on  the  dose.  In  septic  infection  only  a  small  number 
of  organisms  may  get  into  the  blood,  but  they  multiply 
enormously.  The  pus  microbes  cause  true  septicaemia,  and 
reach  the  blood  chiefly  through  the  lymphatics,  but  to  some 
degree  by  penetrating  the  walls  of  vessels.  A  drop  of  blood 
from  a  man-  with  septic  infection  will  reproduce  the  disease 
when  injected  into  the  blood  of  an  animal ;  hence  it  is  a  true 
infective  disease.     The  wound  in  such  cases  is  often  small. 

Syniptoiiis. — The  type  of  this  condition  is  met  with  in 
puerperal  septicaemia  or  a  poisoned  wound.  It  begins,  in 
from  four  to  seven  days  after  labor  or  an  injury,  with  a  chill, 
which  is  followed  by  fever,  at  first  moderate,  but  soon  be- 
coming high.  The  fever  presents  morning  remissions  and 
evening  exacerbations,  and  may  occasionally  show  an  inter- 
mission. The  pulse  is  small,  weak,  very  frequent,  and  com- 
pressible. The  tongue  is  dry  and  brown  with  a  red  tip. 
The  vomiting  is  frequent,  and  diarrhoea  is  the  rule.  Delirium 
alternates  with  stupor,  and  coma  is  usual  before  death. 
Prostration  is  very  great.  Toward  the  end  the  face  often 
becomes  Hippocratic  (p.  79).  Congestions  occur.  Ecchymo- 
ses  and  petechiae  are  noted,  secretions  dry  up,  urinar}^  secre- 
tion is  scanty  or  is  suppressed,  and  the  wound  becomes  dry 
and  brown.  Blood-examination  detects  disintegration  of  red 
globules.  When  a  wound  inaugurates  septicaemia,  red  lines 
of  lymphangitis  are  seen  about  it  and  there  is  enlargement 
of  related  lymphatic  glands.  No  thrombi  or  emboli  exist  in 
septicaemia.  The  prognosis  is  bad,  and  death  may  occur 
within  twenty-four  hours.  The  treatment  is  the  same  as  for 
septic  intoxication. 

Pyaemia. — Pyaemia,  which  is  septicaemia  plus  metastatic 
abscesses,  is  characterized  by  fever  of  an  intermittent  type 


128  A   MANUAL    OF  SURGERY. 

and  by  recurring  chills.  It  is  not  due  to  pus  in  the  blood, 
but  to  the  taking  up  of  clots  infected  by  streptococci  and 
staphylococci. 

In  an  area  of  suppuration  there  are  coagulation  necrosis, 
thrombosis,  and  septic  inflammation  of  the  adjacent  vessels, 
and  the  thrombi  are  infected.  A  vessel-thrombus  reaches 
up  to  the  first  collateral  branch,  and  the  apex  of  the  purulent 
clot  is  broken  off  by  the  blood-stream  from  that  branch  and 
is  carried  as  an  embolus  into  the  circulation.  Many  of  these 
poisonous  emboli  enter  into  the  blood  and  lodge  in  some 
vessels  which  are  too  small  to  transmit  them,  and  at  their 
points  of  lodgment  form  embolic,  secondary,  or  metastatic 
abscesses.  Wounds  of  the  superficial  parts  and  bones  pro- 
duce pysemic  infarctions  or  metastatic  abscesses  of  the  lungs. 
When  these  infarctions  break  into  fragments  particles  may 
return  to  the  heart  and  lodge  there,  or  may  be  sent  out 
through  the  arterial  system  to  form  another  focus  in  the 
kidneys.  Infected  areas  connected  with  the  portal  circula- 
tion (intestinal  injuries  or  suppurating  piles)  produce  abscess 
of  the  liver.  Malignant  endocarditis  is  called  "  arterial 
pyaemia,"  and  is  due  to  endocardial  embolic  infection.  In 
this  disorder  infected  emboli  lodge  in  the  kidneys,  the  spleen, 
the  alimentary  tract,  the  brain,  or  the  skin  (Osier).  Idio- 
pathic pyaemia  is  a  misnomer.  Some  primary  focus  of  in- 
fection must  exist  (often  in  the  ear). 

Symptoms. — The  wound  becomes  dry,  brown,  and  offen- 
sive. A  severe  and  prolonged  chill  or  a  succession  of  chills 
usher  in  the  disease ;  high  fever  follows,  and  a  drenching 
sweat.  These  chills  recur  every  other  day,  every  day,  or 
oftener.  After  the  sweat  the  temperature  falls  and  may 
become  nearly  normal.  The  general  symptoms  of  vomiting, 
wasting,  etc.  resemble  those  of  septicaemia.  The  skin  be- 
comes jaundiced,  and  a  profound  adynamic  state  is  rapidly 
established.     The  spleen  is  enlarged.    The  lodgment  of  em- 


ER  YSIPELAS.  1 29 

boli  produces  symptoms  whose  nature  depends  upon  the 
organ  involved.  Lodgment  in  the  lungs  causes  shortness 
of  breath  and  cough  with  slight  physical  signs.  Lodgment 
in  the  pleura  or  pericardium  gives  pronounced  physical 
evidence.  Lodgment  in  the  spleen  produces  severe  pain 
and  great  enlargement.  The  parotid  gland  not  unusually 
suppurates  (as  in  the  case  of  President  Garfield). 

In  a  suspected  case  of  pyaemia  always  look  for  a  wound, 
and  if  this  does  not  exist,  remember  that  the  infection  can 
arise  from  gonorrhoea,  osteo-myelitis,  suppuration  of  the 
middle  ear,  or  abscess  of  the  prostate.  Chronic  pyemia 
may  last  for  months ;  acute  pyaemia  may  prove  fatal  in  three 
days.  The  complications  are  joint-suppuration,  broncho- 
pneumonia, pleuritis,  endocarditis,  pericarditis,  peritonitis, 
venous  thrombosis,  and  abscesses. 

Treatment  is  the  same  as  for  septicaemia.  Open,  drain,  and 
asepticize  any  wound  and  any  accessible  secondary  abscess. 


X.  ERYSIPELAS  (ST.  ANTHONY'S  FIRE). 
Erysipelas  is  an  acute,  contagious,  capillary  lymphangitis 
due  to  the  streptococcus  of  erysipelas,  which  grows  and 
multiplies  in  the  smaller  lymph-channels  of  the  skin  and  of 
serous  and  mucous  membranes.  It  is  characterized  by  a 
remittent  fever  and  a  tendency  to  recur.  It  is  always  due 
to  a  wound.  Idiopathic  erysipelas  is  due  to  a  small  wound 
which  escapes  notice.  It  may  or  may  not  suppurate.  Sup- 
puration, some  say,  does  not  require  a  mixed  infection,  as 
the  streptococcus  is  identical  with  the  streptococcus  pyogenes 
(Osier,  Koch) ;  others  think  suppuration  does  require  mixed 
infection,  the  streptococcus  not  being  pyogenic.  Erysipelas 
is  most  common  in  the  spring  and  fall,  and  is  most  usually 
met  with  among  those  who  are  crowded  into  dark,  dirty, 
and  ill-ventilated  quarters  ;  it  attacks  by  preference  the  debil- 


130  A   MANUAL    OF  SURGERY. 

itated  and  broken-down  (as  alcoholics  and  sufferers  from 
Bright's  disease).  The  poison  of  erysipelas  will  produce 
puerperal  fever  in  a  lying-in  woman. 

Forms  of  Erysipelas. — Ambulant,  erratic,  migratory ,  or 
wandering  erysipelas  is  a  form  which  tends  to  spread  widely 
over  the  body,  leaving  one  part  and  going  to  another. 
Billions  erysipelas  is  attended  by  the  formation  of  bullae. 
In  diffnseci  erysipelas  the  borders  of  the  inflammation  grad- 
ually merge  into  healthy  skin.  Erythematous  erysipelas 
involves  the  skin  superficially.  Metastatic  erysipelas  appears 
in  various  parts  of  the  body.  Puerperal  erysipelas  begins 
in  the  genitals  of  lying-in  women,  producing  puerperal 
fever.  Erysipelas  simplex  is  ordinarily  cutaneous.  Erysip- 
elas neonatorum  begins  in  the  unhealed  navel  of  a  new-born 
child  and  spreads  from  this  point.  Typhoid  erysipelas 
occurs  with  profound  adynamia.  Universal  erysipelas  in- 
volves the  entire  body.  Phlegmonous  erysipelas  involves  the 
skin  and  subcutaneous  tissues,  with  suppuration,  and  often 
with  gangrene.  Qidematous  erysipelas  is  a  variety  of  phleg- 
monous erysipelas  with  enormous  subcutaneous  oedema. 
Lymphatic  erysipelas  is  characterized  by  rose-red  lines  of 
lymphangitis.  Venoiis  erysipelas  is  marked  by  the  dark 
color  of  venous  congestion.  Mucous  erysipelas  involves  a 
mucous  membrane.    Black  tongue  is  erysipelas  of  the  fauces. 

Clinical  Forms. — The  clinical  forms  are  cutaneous  ery- 
sipelas, cellulo-cutaneous  or  phlegmonous,  and  cellulitis. 

Cutaneous  erysipelas  is  ushered  in  by  a  chill  which  is 
followed  by  fever  and  sweat.  Any  wound  which  exists 
becomes  dry  and  unhealthy,  and  its  edges  redden  and  swell. 
This  combination  of  redness  and  swelling  extends,  and  its 
area  is  sharply  defined  from  the  healthy  skin.  In  the  hyper- 
aemic  area  vesicles  or  bullae  form,  and  oedema  affects  the 
subcutaneous  tissues,  producing  great  swelling  in  regions 
where  they  are  lax  (as  in  the  eyelids).     The  anatomically 


ER  YSIPELAS.  1 3 1 

related  lymphatic  glands  become  large  and  tender,  and 
between  them  and  a  wound  are  seen  the  red  lines  of  inflamed 
lymphatic  vessels.  Erysipelas  spreads  at  its  periphery  and 
fades  at  its  point  of  origin.  When  spreading  stops  the  swell- 
ing and  redness  gradually  abate,  and  after  they  disappear 
desquamation  takes  place.  Cutaneous  erysipelas  rarely  sup- 
purates, but  may  do  so.  The  fever  is  remittent,  and  usually 
terminates  in  four  or  five  days  by  crisis. 

In  strong  subjects  the  symptoms  are  usually  slight.  In 
the  old,  debilitated,  or  alcoholic  the  symptoms  are  typhoid, 
delirium  comes  on,  and  death  is  apt  to  occur.  Possible  compli- 
cations are  meningitis,  pneumonia,  septicaemia,  endocarditis, 
and  albuminuria.     Erysipelas  neonatorum  is  generally  fatal. 

Treatment. — Isolate  the  patient  and  asepticize  any  wound. 
Cases  of  cutaneous  erysipelas  tend  to  get  well  without 
treatment.  If  a  person  is  debilitated,  stimulate  freely.  Tinc- 
ture of  chloride  of  iron  and  quinine  are  usually  administered. 
Nutritious  food  is  important.  For  sleeplessness  or  delirium 
use  chloral  or  the  bromides ;  for  high  temperature,  cold 
sponging  and  antipyretics.  To  prevent  spreading,  inject  the 
healthy  skin  near  the  blush  with  a  2  per  cent,  carbolic  solu- 
tion or  with  gr.  -^^  of  corrosive  sublimate.  LocalI\',  paint 
the  inflamed  area  with  equal  parts  of  iodine  and  alcohol 
and  apply  lead-water  and  laudanum.  If  an  extremity  be 
involved,  bandage  it.  Another  good  treatment  is  a  50  per 
cent,  ichthyol  ointment  with  lanolin.  Some  use  iced-water 
cloths.  Others  apply  borated  talc  or  salicylated  starch. 
Ringer  advised  painting  every  three  hours  with  a  mixture 
composed  of  gr.  xxx  of  tannic  acid,  gr.  xxx  of  camphor, 
and  oiv  of  ether.     Da  Costa  recommends  pilocarpine. 

Cellulo-cutaneous  or  phlegmonous  erysipelas  is  char- 
acterized by  high  temperature  (i04°-lo6°),  the  rapid  onset 
of  grave  prostration,  irregular  chills,  sweats,  and  a  strong 
tendency  to  delirium.    The  parts  are  not  so  red  as  in  the  pre- 


132  A   MANUAL    OF  SURGERY. 

vious  form,  but  the  tumefaction  is  vastly  greater ;  it  is  branny, 
comes  on  early  and  with  exceeding  rapidity,  inducing  a  high 
degree  of  tension  and  frequently  producing  sloughing  or 
even  cutaneous  gangrene.  The  lymphatic  glands  are  swol- 
len, but  the  inflamed  vessels  are  hidden  by  the  swelling. 
In  most  cases  suppuration  occurs,  and  when  this  happens 
the  parts  become  boggy.  When  the  disease  abates  sloughs 
form,  which  leave  ulcers  upon  being  thrown  off.  In  bad 
cases  muscles,  vessels,  tendons,  and  fascia  may  slough  away^ 
The  commonest  complications  are  suppression  of  urine, 
broncho-pneumonia,  congestion  and  oedema  of  the  lungs, 
meningitis,  and  acute  pleurisy. 

Treatment. — At  once  asepticize  and  drain  any  existing 
wound;  apply  iodine  and  blue  ointment  or  ichthyol  or  lead- 
water  and  laudanum  to  the  inflamed  area,  and  if  a  limb  is 
involved  use  a  roller-bandage  and  a  sling.  Open  the  bowels 
with  calomel  and  salines  ;  order  quinine,  iron,  stimulants,  and 
nourishing  diet.  If  suppuration  occurs,  make  many  incisions 
near  together,  each  cut  being  2  or  3  inches  long.  Spray  out 
by  means  of  hydrogen  peroxide  in  an  atomizer,  and  then 
wash  with  corrosive-sublimate  solution  (i  :  1000).  Drain  by 
means  of  iodoform  gauze  in  strips.  Excise  spots  of  gan- 
grene. Dress  with  many  layers  of  wet  gauze,  which  is  to 
be  enveloped  in  a  rubber  dam  after  application,  or  with  dry 
gauze  and  iodoform.  If  sloughs  form,  cut  them  partly  away 
and  employ  antiseptic  poultices.  Apply  a  bandage  to  an 
extremity  which  is  attacked  by  this  form  of  erysipelas. 
Change  dressings  often.  When  granulations  begin  to  form, 
treat  as  a  healing  wound. 

Cellulitis. — In  cellulitis  redness  of  the  skin  is  not  very 
pronounced  and  is  late  in  appearing,  following  swelling,  and 
not  preceding  it.  It  is  essentially  the  same  condition  as 
phlegmonous  erysipelas.  It  is  often  mild  in  degree.  Its 
spread  is  heralded  by  red  lines  of  lymphangitis,  swelling  of 


TETANUS,    OR   LOCKJAW.  1 33 

glands,  and  fever.     In  slight  cases  the  lymphatics  may  dis- 
pose of  the  poison  and  suppuration  fail  to  occur. 

T7'edtinent. — The  treatment  is  the  same  as  that  for  phleg- 
monous erysipelas. 


XI.   TETANUS,  OR   LOCKJAW. 

Tetanus  is  an  infectious  spasmodic  disease  invariably 
preceded  by  some  injury.  The  wound  may  have  been  so 
slight  as  to  have  attracted  no  attention,  or  it  may  have  been 
inflicted  upon  the  alimentary  canal  by  a  fish-bone  or  other 
foreign  body.  Idiopathic  tetanus  is  either  not  tetanus  at  all 
or  is  a  term  expressive  of  the  fact  that  we  have  not  found 
an  injury  which  did  exist.  This  disease  is  commonest  after 
punctured  or  lacerated  wounds  of  the  hands  or  feet,  and  be- 
fore it  appears  a  wound  is  apt  to  suppurate  or  slough  ;  but  in 
some  instances  the  wound  is  found  soundly  healed.  Tetanus 
may  appear  twenty-four  hours  after  an  accident,  but  it  may 
not  arise  until  several  weeks  have  elapsed.  It  prevails  more 
in  certain  localities  than  in  others.  Colored  people  are  very 
susceptible,  and  it  may  exist  epidemically.  Tetanus  is  due 
to  infection  by  a  bacillus  (first  described  by  Nicolaier)  whose 
toxic  products,  absorbed  from  the  infected  area,  poison  the  ner- 
vous system  precisely  as  would  dosing  with  strychnine.  This 
bacillus  is  found  particularly  in  garden-soil,  in  the  dust  of  walls, 
walks,  and  cellars,  in  street-dirt,  and  in  the  refuse  of  stables. 

Symptoms. — Acute  tetanus  usually  begins  within  nine  days 
of  an  accident.  First  the  neck  feels  stiff,  the  patient  think- 
ing he  has  taken  cold,  and  next  the  jaws  also  become  stiff 
The  neck  becomes  like  an  iron  bar,  and  the  jaws  become 
as  rigid  as  steel.  The  muscles  of  deglutition  become  rigid 
on  attempts  at  swallowing.  The  muscles  of  the  back,  legs, 
and  abdomen  are  thrown  into  tonic  spasm,  but  the  arms 
rarely  suffer.     Spasm  of  the  face-muscles  causes  the  risus 


134  A   MANUAL    OF  SURGERY. 

sardoniais,  or  sardonic  smile  (contraction  particularly  of  the 
musailiis  sardoiiiciis  of  Santorini).  The  contraction  of  the 
muscles  of  the  back  is  often  so  powerful  as  to  bend  the 
patient  back  like  a  bow  and  allow  him  to  rest  only  on  his 
occiput  and  heels.  This  condition  is  known  as  "  opisthot- 
onos." If  he  is  bent  forward  so  that  the  face  is  drawn  to 
the  legs,  it  is  called  "  emprosthotonos."  If  his  body  is  curved 
sideways,  it  is  designated  "pleurosthotonos."  An  upright 
position  is  "  orthotonos." 

The  state  is  one  of  widely-diffused  tonic  spasm,  aggravated 
frequently  by  clonic  spasms  arising  from  peripheral  irrita- 
tions. These  irritations  may  be  draughts,  sounds,  lights, 
shaking  of  the  bed,  attempts  at  swallowing,  contact  of  the 
bed-clothing,  the  presence  of  urine  in  the  bladder  or  of  feces 
in  the  rectum,  or  various  visceral  actions.  The  agonizing 
''  girdle-pain  "  so  often  met  with  means  spasm  of  the  dia- 
phragm. Each  clonic  spasm  causes  a  hideous  scream  by 
the  contraction  of  the  chest  forcing  air  through  a  contracted 
glottis.  Constipation  is  persistent ;  retention  of  urine  is  the 
rule.  The  mind  is  entirely  clear — one  of  the  worst  ele- 
ments of  the  disease.  Swallowing  is  absolutely  impossible. 
The  temperature  may  be  normal,  but  it  is  usually  a  little 
elevated.  Hyperpyrexia  sometimes  occurs  (io8°-iio°),  and 
the  temperature  may  even  ascend  for  a  time  after  death. 
Sleep  is  impossible.  Death  almost  invariably  occurs  in 
acute  tetanus  in  two  or  three  days.  It  may  be  due  to 
exhaustion  or  to  carbonic-acid  narcosis  from  spasm  of  the 
glottis  or  fixation  of  the  respiratory  muscles. 

Chronic  tetanus  comes  on  late  after  a  wound  (from  ten 
days  to  several  weeks).  The  symptoms  are  not  so  severe ; 
the  muscular  spasm  is  widespread,  but  it  may  not  be  per- 
sistent, intervals  of  relaxation  permitting  sleep  and  the  taking 
of  food.  It  may  last  some  weeks,  and  not  infrequently  the 
disease  can  be  cured.     Trisnms  is  a  mild  form  of  tetanus, 


TETANUS,    OR   LOCKJAW. 


135 


the  contractions  being  limited  to  the  face  and  jaw.  Trismus 
neonatorum  or  trismus  nascejitium,  which  is  lockjaw  in  the 
new-born,  is  due  to  infection  of  the  stump  of  the  umbilical 
cord,  and  is  invariably  fatal. 

Diagnosis. — Tetanus  may  be  confounded  with  strychnine- 
poisoning  or  with  hysteria.  Wood's  table  makes  the  diagno- 
sis clear.^ 


Tetanus. 


Hysterical  Tetanus. 


Muscular  symptoms 
usually  commence 
with  pain  and  stiffness 
in  the  back  of  the 
neck,  sometimes  with 
slight  muscular  twitch- 
ings  ;  come  on  gradu- 
ally. Jaw  one  of  the 
earliest  parts  affected ; 
rigidly  and  persistent- 
ly set. 

Persistent  muscular 
rigidity  very  generally, 
with  a  greater  or  less 
degree  of  permanent 
opisthotonos,  empros- 
thotonos,  pleurosthot- 
onos,  or  orthotonos. 


Consciousness  pre- 
sers'ed  until  near 
death, as  in  strjxhnine- 
poisoning. 


Commences     with 
blindness  and  weakness. 


Strychnine-poisoning. 


Muscular  symptoms 
commence  with  rigidity 
of  the  neck  which  creeps 
over  the  body,  affecdng 
the  extremities  last.  Jaws 
rigidly  set  before  a  con- 
vulsion, and  remain  so 
between  the  paroxysms. 


Persistent  opisthoto- 
nos and  intense  rigidity 
between  the  convulsions 
and  after  the  convulsions 
have  ceased,  the  opis- 
thotonos and  intense  rig- 
idity lasting  for  hours. 


Consciousness  lost  as 
the  second  convulsion 
comeS'-6n,  and  lost  with 
every  other  convulsion, 
the  disturbance  of  con- 
sciousness and  motility 
being  simultaneous. 


Begins  with  exhilaration  and 
restlessness,  the  special  senses 
being  usually  much  sharpened. 
Dimness  of  vision  may  in  some 
cases  be  manifested  later,  after 
the  development  of  other  symp- 
toms, but  even  then  it  is  rare. 

Muscular  symptoms  develop 
very  rapidly,  commencing  in  the 
extremities,  or  the  convulsion 
when  the  dose  is  large  seizes 
the  whole  body  simultaneously. 
Jaw  the  last  part  of  the  body 
to  be  affected ;  its  muscles  re- 
lax first,  and  even  when,  during 
a  severe  convulsion,  it  is  set,  it 
drops  as  soon  as  the  latter  ceases. 

Muscular  relaxation  (rarely  a 
slight  rigidity)  between  the  con- 
vulsions, the  patient  being  ex- 
hausted and  sweating.  If  re- 
covery occurs,  the  convulsions 
gradually  cease,  leaving  merely 
muscular  soreness,  and  some- 
times stiffness  like  that  felt  after 
violent  exercise. 

Consciousness  always  pre- 
served during  convulsions,  ex- 
cept when  the  latter  become  so 
intense  that  death  is  imminent 
from  suffocation,  in  which  case 
sometimes  the  patient  becomes 
insensible  from  asphyxia,  which 
comes  on  during  the  latter  part 
of  a  convulsion  and  is  almost  a 
certain  precursor  of  death. 


"^  N'ervous  Diseases,  by  Prof.  H.  C.  Wood, 


136 


A   MANUAL    OF  SURGERY. 


Tetanus. 


Draughts,  loud 
noises,  etc.  produce 
convulsions,  as  in 
strychnine-poisoning ; 
may  complain  bitterly 
of  pain. 

Eyes  open  and  rig- 
idly fixed  during  the 
convulsion. 


Hysterical  Tetanus. 


Crying-spells  alternat- 
ing with  convulsions. 


Eyes  closed. 


Strychnine-poisoning. 


The  "slightest  breath  of  air" 
produces  convulsion.  Patient 
may  scream  with  pain  or  may 
express  great  apprehensions,  but 
"crying-spells"  would  appear 
to  be  impossible. 

Eyes  stretched  wide  open. 


Legs  stiffly  extended  with 
feet  everted,  as  the  spasms  affect 
all  the  muscles  of  the  leg. 


Partial  spasm  in  the 
leg,  producing  in  Wood's 
cases  crossing  of  the  feet 
and  inversion  of  the  toes. 
If  all  the  muscles  were 
involved  eversion  would 
occur,  as  the  muscles  of 
eversion  are  the  stronger. 

Treatment. — Far  better  than  even  to  treat  tetanus  well  is 
to  prevent  it.  Careful  antisepsis  will  banish  it  as  thoroughly 
as  it  has  banished  septicaemia.  Every  wound  must  be  dis- 
infected with  the  most  scrupulous  care.  Every  punctured 
wound  is  to  be  incised  to  its  depth  and  thoroughly  cleaned 
and  drained.  Puerperal  tetanus  is  prevented  by  antiseptic 
midwifery,  and  tetanus  neonatorum  is  obviated  by  the  anti- 
septic treatment  of  the  stump  of  the  cord.  When  tetanus 
exists,  always  look  for  a  wound,  and  if  one  is  found,  open  it, 
cut  away  sloughs,  wash  with  peroxide  of  hydrogen  and  cor- 
rosive sublimate,  swab  it  out  with  bromine,  and  secure  drain- 
age by  packing  it  with  iodoform  gauze. 

Isolate  the  patient,  as  the  disease  is  infective ;  keep  him 
in  a  darkened,  well-ventilated,  and  quiet  apartment,  so  as  to 
exclude  as  far  as  possible  peripheral  irritation.  Watch  out 
for  retention  of  urine,  and  use  the  catheter  if  it  occurs. 
Secure  movements  of  the  bowels  by  salines,  castor  oil,  croton 
oil,  or  enemas.  Give  plenty  of  concentrated  liquid  food,  and 
stimulate  freely  with  alcohol.  If  swallowing  causes  convul- 
sions, give  an  inhalation  of  nitrite  of  amyl  before  an  attempt 
is  made  to  swallow.     If  this  treatment  fails,  partially  anaes- 


TUBERCULOSIS  AND   SCROFULA.  I  37 

thetize  the  patient  and  feed  him  through  a  pharyngeal  tube 
passed  through  the  nose.  Large  doses  of  the  bromide  of 
potassium  or  of  this  drug  with  chloral  give  the  best  results. 
Other  drues  that  have  been  used  with  some  success  are 
gelsemium,  morphia,  curare,  injections  and  fomentations  of 
tobacco,  physostigma,  anaesthetics,  cocaine,  and  cannabis 
indica.  An  ice-bag  to  the  spine  somewhat  relieves  the 
girdle-pain.     Hot  baths  have  been  advised. 

Yandell  says,  in  summing  up  Cowling's  report  on  tetanus  •} 
"  Recoveries  from  traumatic  tetanus  have  been  usually  in 
cases  in  which  the  disease  occurs  subsequent  to  nine  days 
after  the  injury.  When  the  symptoms  last  fourteen  days, 
recovery  is  the  rule,  apparently  independent  of  treatment. 
The  true  test  of  a  remedy  is  its  influence  on  the  history  of 
the  disease.  Does  it  cure  cases  in  which  the  disease  has  set 
in  previous  to  the  ninth  day  ?  Does  it  fail  in  cases  whose  du- 
ration exceeds  fourteen  days  ?  No  agent  tried  by  these  tests 
has  yet  established  its  claims  as  a  true  remedy  for  tetanus."^ 

It  is  now  claimed  by  some  observers  that  we  have  a  rem- 
edy which  fulfils  the  requirements  of  Yandell  in  the  tetanus 
antitoxine  of  Tizzoni  and  Kitasato.  To  prepare  this  anti- 
toxine  animals  are  rendered  immune  to  tetanus  by  inocula- 
tions with  mitigated  cultivations  of  the  microbe ;  the  blood- 
serum  is  treated  with  alcohol  and  dried  in  a  vacuum.  This 
is  used  hypodermatically  in  doses  of  from  15  to  25  centi- 
grammes. Cures  seem  to  have  followed  its  use,  and  if  it 
can  be  obtained  it  is  our  duty  to  try  it  in  acute  tetanus. 

XII.   TUBERCULOSIS   AND    SCROFULA. 
Tuberculosis  is  an  infective  disease  due  to  the  deposition 
and  multiphcation  of  the  bacilli  of  tubercle  in  the  tissues 

^American  Practitioner,  Sept.,   1870. 

2  Quoted  by  Hammond   in  his  Diseases  of  the  N'ervous  System. 


138  A   MANUAL    OF  SURGERY. 

of  the  body.  It  is  characterized  either  by  the  formation  of 
tubercles  or  by  a  widespread  infiltration,  both  of  these  con- 
ditions tending  toward  caseation,  sclerosis,  or  ulceration. 
A  tubercular  lesion  may  undergo  calcification. 

Bacillus  of  Tubercle. — A  tubercle  is  an  infective  granu- 
loma, appearing  to  the  unaided  vision  as  a  semi-transparent 
gray  mass  the  size  of  a  mustard-seed.  The  microscope  shows 
that  a  gray  tubercle  consists  of  a  number  of  cell-clusters, 
each  cluster  constituting  a  primitive  tubercle.  A  typical 
primitive   tubercle   shows  a  centre  consisting  of  one  or  of 

several  polynucleated  giant-cells  sur- 
rounded by  a  zone  of  epithelioid  cells 
which  are  surrounded  by  an  area  of 
leucocytes.     When  the  bacillus  ob- 
-^.    tains  a  lodgment  the  fixed  connective- 
tissue  cells  multiply  by  karyokinesis, 
'\^^^i^%l  forming  amass  of  nucleated  polygonal 
^WSplf^lelfe  or  round   cells,  called  ''epithelioid" 
^M'^%^^\kf^^;:^^^  from  their  resemblance  to  epithelial 

cells,  and  at  the  same  time  the  blood- 
supply  of  the   growth  is  limited  by 
,  „     .   ., ^'f    occlusion   of  surroundins:  vessels 

0  9    •   ...   '^    •  •  (Yii'\9* 
Fig.   3o.-Synovial    Membrane.     thrOUgh   multiplication  of  their  Cndo- 

showing  giant-cells  (Bowiby).  thcHal  coats.  Somc  of  thesc  epitheli- 
oid cells  proliferate,  and  others  attempt  to,  but  fail  for  want 
of  blood-supply.  Those  that  fail  succeed  only  in  dividing 
their  nuclei  and  enormously  increasing  their  bulk  (giant-cells). 
Giant-cells,  which  also  form  by  a  coalescence  of  epithelioid 
cells,  are  not  always  present.  The  presence  of  this  mass  of 
cells  causes  surrounding  inflammation  and  the  exudation 
of  white  blood-cells  (Fig.  30). 

The  bacillus,  when  found,  exists  in  the  epithelioid  cells,  and 
sometimes  in  the  giant-cells ;  it  may  not  be  found,  having  once 
existed,  but  having  been  subsequently  destroyed.    It  is  often 


TUBERCULOSIS  AND   SCROFULA.  139 

overlooked.  In  a  lesion  of  active  tubercle,  even  if  the  bacil- 
lus be  not  found,  injection  of  the  matter  into  a  guinea-pig 
will  produce  lesions  in  which  it  can  be  demonstrated.  A 
tubercle  may  caseate — a  process  that  is  destructive  and  dan- 
gerous to  the  organism.  Caseation  is  due  to  a  coagulation 
necrosis  arising  from  direct  microbic  action  upon  a  cellular 
area  which  contains  no  blood-vessels,  and  the  nutrition  is 
cut  off  by  obliteration  of  surrounding  vessels.  This  pro- 
cess starts  at  the  centre,  and  the  entire  tubercle  becomes 
converted  into  a  soft  yellowish-gray  mass.  Caseation 
forms  cheesy  masses  which  may  soften  into  tuberculous 
pus,  may  calcify,  and  may  become  encapsuled  by  fibroid 
tissue. 

A  tubercle  may  undergo  sclerosis,  which  is  an  attempt  on 
the  part  of  Nature  to  heal  and  repair.  Coagulation  necrosis 
occurs  in  the  centre  of  the  tubercle ;  "  hyaline  transformation 
proceeds,  together  with  a  great  increase  in  the  fibroid  ele- 
ments, so  that  the  tubercle  is  converted  into  a  firm,  hard 
structure  "  (Osier).  Infiltrated  tubercle  is  due  to  the  running 
together  of  many  minute  infective  foci  or  to  widespread 
infiltration  without  any  foci.  Infiltrated  tubercle  tends  strongly 
to  caseate. 

The  bacillus  of  tubercle,  discovered  by  Koch,  is  a  little 
rod  with  a  length  equal  to  about  half  the  diameter  of  a  red 
blood-corpuscle.  It  can  be  stained  by  aniline,  and  this  stain 
is  not  removable  by  acids  (it  being  the  only  bacillus  except 
leprosy  which  acts  in  this  way.)  In  its  growth  the  tubercle 
bacillus  forms  ptomaines,  toxalbumins,  and  an  antitoxine. 
These  bacilli  exist  in  all  active  lesions  :  the  more  active  the 
process  the  greater  is  their  number.  They  may  be  widely 
distributed,  but  are  rarely  identified  in  the  blood.  They 
exist  in  enormous  numbers  in  phthisical  sputum,  but  are  not 
found  in  the  breath  of  consumptives.  Their  great  medium 
of  distribution  is  dried  sputum  mixed  with  dust.     They  are 


140  A   MANUAL    OF  SURGERY. 

found  in  the  milk  of  tuberculous  cows,  and  sometimes  in  the 
meat  of  diseased  animals. 

Infection  may  be  due  to  hereditary  transmission.  Con- 
genital tuberculosis  is  occasionally,  though  rarely,  seen. 
Tuberculosis  is  apt  to  appear  in  young  children.  Some 
think  this  is  due  to  infection  from  without  upon  tissues 
whose  resistance  is  lowered  by  hereditary  predisposition ; 
others  think  it  is  due  to  a  tardy  development  of  the  germs 
transmitted  by  heredity.  That  the  disease  may  be  present 
in  a  latent  form  is  shown  by  the  experiment  in  which  the 
viscera  of  the  foetus  of  a  consumptive  mother  showed  no 
tubercles,  but  produced  the  disease  in  guinea-pigs  when 
inoculated.^  Tuberculosis  may  arise  by  inoculation,  inocu- 
lation tuberculosis  being  seen  in  leather-workers  and  in  those 
who  dissect  tuberculous  bodies  (butchers  and  doctors  are 
liable  to  anatomical  tubercle).  Osier  mentions  as  other  causes 
of  inoculation  the  bite  of  a  tuberculous  patient,  the  washing 
of  infected  garments,  and  circumcision  in  which  suction  is 
employed.  Infection  through  the  air  is  very  common.  The 
bacteria  of  the  dried  sputum  adhere  to  particles  of  dust  and 
are  carried  into  the  lungs.  Infection  by  meat,  milk,  and  other 
foods  may  arise  by  this  dust  settling  upon  them  in  quantity. 
Commonly,  however,  it  is  due  to  disease  of  the  animals. 
Milk  is  a  common  vehicle  of  contagion,  and  it  can  be  in- 
fected even  when  an  ulcerated  udder  does  not  exist. 

Infection  is  favored  by  hereditary  predisposition — that  is 
to  say,  by  hereditary  tissue- weakness,  which,  by  maintaining 
a  lowered  momentum  of  nutritive  processes,  lessens  the  nor- 
mal resistance  to  infection.  Two  types  of  these  predisposed 
persons  are  mentioned  :  (i)  the  sanguine  type  of  scrofula,  or 
those  with  oval  faces,  clear  skin,  large  blue  eyes,  long  lashes, 
a  nervous  manner,  precocious  minds,  but  little  fat,  and  with 
long  slender  bones,  these  children  being  often  graceful  and 
^  Quoted  by  Osier  from  Birch- Hirschfeld. 


TUBERCULOSIS  AND  SCROFULA.  141 

beautiful ;  and  (2)  those  with  stoHd  countenances,  thick  hps 
and  noses,  thick  muddy  skin,  dark  coarse  hair,  swollen  necks, 
heavy  bones,  clumsy  gait,  and  ungainly  figure.  The  latter 
type  is  the  phlegmatic  form  of  scrofula. 

There  is  no  doubt  that  an  inflammatory  area  in  a  person 
can  become  infected  when  a  sound  area  would  escape,  the 
process  of  phagocytosis  being  in  this  spot  limited  in  power, 
and  the  organisms,  which  are  destroyed  by  healthy  cell- 
activities,  are  victorious  when  those  activities  are  diminished. 
Catarrhal  inflammations  of  the  air-passages  favor  phthisis, 
and  traumatism  is  not  unusually  followed  by  a  development 
of  tubercle.  Lowered  health,  impure  air,  and  bad  food  all 
favor  the  development  of  tubercle.  Any  tuberculous  pro- 
cess tends  to  spread  locally  and  to  produce  inflammation. 
A  tubercular  area  is  always  a  danger  to  the  system ;  from 
this  as  a  focus  dissemination  may  occur,  tuberculous  lesions 
appearing  in  a  distant  part  or  general  tuberculosis  setting  in. 
Tuberculous  pus  is  not  pus.  True  pus  means  a  secondary 
infection  (see   Cold  Abscess,  p.  loo). 

Scrofula  is  not  a  disease.  It  is  a  condition  of  tissues 
in  which  low  resisting  power  makes  them  hospitable  hosts 
to  invading  bacilli  of  tubercle.  Some  observers  teach  that 
scrofula  is  tuberculosis  of  bones,  glands,  and  joints;  others 
teach  that  it  is  latent  tuberculosis  until  some  cause  lights  it 
into  activity ;  while  still  others  say  that  it  is  a  tendency 
rather  than  a  disease.  It  is  certain  that  some  lesions  of 
scrofula  are  not  tuberculous  (eczema  capitis,  facial  eczema, 
corneal  ulcers,  granular  lids,  and  chronic  catarrhal  inflam- 
mations), and  that  they  result  from  ill-health,  poor  nutrition, 
bad  air,  and  improper  diet.  A  person  who  is  recognized  as 
of  a  scrofulous  type  may  never  develop  tuberculous  lesions. 
It  is  unquestionable,  however,  that  strumous  subjects  are 
peculiarly  apt  to  develop  true  tuberculous  lesions.  These 
lesions  often  appear  after  a  tissue  or  an  organ  has  become 


142  A   MANUAL    OF  SURGERY. 

the  seat  of  a  primary  non-tubercular  inflammation ;  the 
bacilli,  which  could  not  hve  in  the  non-inflamed  tissue, 
thrive  in  the  inflamed  tissue.  Scrofula  is  generally  of 
congenital  origin,  one  or  both  parents  being  tuberculous, 
scrofulous,  or  in  ill-health ;  it  may,  however,  be  acquired  as 
a  result  of  poor  food,  bad  air,  crowding,  and  general  lack 
of  sanitation.  The  scrofulous  are  very  prone  to  develop 
tuberculous  lesions  of  bones,  joints,  and  lymphatic  glands. 

Tuberculous  Abscess. — For  description  of  tuberculous 
abscess,  see  page  97. 

Tuberculosis  of  the  Skin. — Lupus  begins  before  the  age 
of  twenty-five,  most  usually  upon  the  face,  especially  the 
nose.  Three  forms  are  recognized :  (i)  lupus  vulgaris,  in 
which  nodules  appear  that  after  a  time  ulcerate  and  then 
cicatrize ;  (2)  lupus  exedens,  in  which  ulceration  is  very 
great ;  and  (3)  lupus  hypcrtropJiicus,  in  which  a  very  great 
amount  of  embryonic  tissue  is  produced  (large  nodules  or 
tubercles).  Lupus  may  appear  as  a  pimple,  as  a  group  of 
pimples,  or  as  nodules  of  a  larger  size.  The  ulcer  arises 
from  desquamation,  and  is  surrounded  by  inflammatory 
products  which,  by  progressively  breaking  down,  add  to  its 
size.  The  ulcer  is  often  crusted  over ;  it  may  be  progress- 
ing at  one  point  and  healing  at  another;  and  it  is  slow  in 
advancing,  but  often  proves  hideously  destructive.  The  scars 
left  by  its  healing  are  apt  to  break  down.  Clinically  it  is 
separated  from  a  rodent  ulcer  by  the  absence  of  a  hard  base 
(W.  Joseph  Hearn). 

Anatomical  tubercle,  the  verruca  nccrogenica  of  Wilks,  is 
due  to  local  inoculation  with,  tuberculous  matter.  It  is  seen 
in  surgeons,  the  makers  of  post-mortems,  leather-workers, 
and  butchers,  usually  upon  the  backs  of  the  hands  and  fin- 
gers. It  consists  of  a  red  mass  of  granulation  tissue  having  the 
appearance  of  a  group  of  inflamed  w^arts.  Pustules  often  form. 
Scrofulodermata  or  scrofulous  gummata  are    chronic 


TUBERCULOSIS  AND   SCROFULA.  1 43 

skin -inflammations    from    granulation    tissue    which    breaks 
down  to  form  small  abscesses  or  sinuses. 

Tuberculosis  of  Subcutaneous  Connective  Tissue. — In 
this  form  of  tuberculosis  nodules  of  granulation  tissue  form 
and  break  down  (tuberculous  abscesses).  In  the  deeper  tis- 
sues these  abscesses  are  usually  associated  with  bone-,  joint-, 
or  lymphatic-gland  disease.  A  large  abscess  is  called  "  cold  " 
(see   Cold  Abscess,  p.  lOo). 

Tuberculosis  of  the  Alimentary  Canal. — A  tuberculous 
ulcer  of  the  lip  occasionally  occurs,  and  is  usually  mistaken 
for  a  cancer  or  a  chancre.  A  tuberculous  ulcer  of  the  tongue 
is  commonly  associated  with  other  foci  of  disease.  It  is 
separated  from  cancer  by  the  absence  of  glandular  enlarge- 
ments, and  from  syphilitic  processes  by  the  therapeutic  test. 
Confirmation  of  the  diagnosis  is  obtained  by  cultivations 
and  inoculations.  Tubercle  may  affect  the  pharynx,  palate, 
tonsils,  and  very  rarely  the  stomach. 

Intestinal  tuberculosis  ordinarily  follows  pulmonary  tu- 
bercle, but  it  may  arise  in  the  mucous  membrane  of  the  bowel 
or  result  from  tuberculous  peritonitis.  Intestinal  tuberculosis 
may  cause  diarrhoea  and  fever,  may  resemble  appendicitis, 
and  may  cause  abscess  and  perforation.  Fistula  in  ano  is 
very  often  tuberculous,  and  when  it  is  the  lungs  are  almost 
always  involved,  the  pulmonary  lesion  being  primary. 

Tuberculosis  of  the  liver  causes  cold  abscess  and  scir- 
rhosis.  Tubercle  may  affect  the  kidneys,  bladder,  ureters. 
Fallopian  tubes,  prostate,  urethra,  seminal  vesicles,  ovaries, 
and  uterus.  Tuberculous  testicle  is  not  rare.  Tuberculous 
orchitis  affects  one  testicle  at  first,  but  the  other  usually 
becomes  involved.  It  starts  in  the  epididymis  as  a  painless 
nodule.  As  the  vaginal  tunic  and  testicle  become  involved 
a  hydrocele  forms.  The  tuberculous  mass  softens,  becomes 
adherent  to  the  scrotum,  and  bursts.  The  cord  is  always 
more  or  less  involved. 


144  A   MANUAL    OF  SURGERY. 

Peritoneal  tuberculosis  may  be  primary,  may  be  part  of  a 
diffused  process,  or  may  follow  intestinal  tubercle.  The  germ 
may  have  entered  by  the  Fallopian  tube.  It  causes  usually 
ascites,  tympany,  and  tumor-like  formations  composed  of 
adherent  bunches  of  bowel  or  omentum  or  distended  mesen- 
teric glands.  Tubercles  may  attack  the  pleura  or  pericar- 
dium. 

Tuberculosis  of  the  brain  induces  meningitis  and  hydro- 
cephalus. 

Tuberculous  disease  of  the  joints  is  called  "  white  swell- 
ing "  and  pulpy  degeneration  of  the  synovial  membrane.  It 
may  begin  in  the  synovial  membrane,  but  it  usually  starts  in 
the  head  of  a  bone,  dry  caries  resulting,  necrosis  ensuing,  or 
an  abscess  forming  which  breaks  into  the  joint.  In  the 
knee-joint  the  disease  begins  as  a  tuberculous  synovitis,  in 
the  hip-joint  as  a  tuberculous  osteitis  of  the  head  of  the  bone. 

Tuberculosis  of  lymphatic  glands  is  known  as  "  tubercu- 
lous adenitis."  It  is  the  most  typical  lesion  of  scrofula.  The 
common  antecedent  of  a  tuberculous  adenitis  of  the  neck  is 
slight  glandular  enlargement  as  a  result  of  catarrhal  inflam- 
mation of  the  mucous  membrane  of  the  mouth.  A  man  not 
of  the  scrofulous  type  can  acquire  tuberculosis  of  the  glands, 
but  adenitis  is  unquestionably  of  much  greater  frequency 
in  the  scrofulous.  Tuberculous  glands  may  get  well  and 
will  often  calcify.  After  healing  they  may  break  down  and 
soften  (residual  abscess).  They  very  frequently  suppurate. 
Though  at  first  a  local  disease,  inflamed  glands  may  be  foci 
of  infection,  and  may  poison  distant  organs  or  the  entire 
system.  Glandular  enlargement  is  in  rare  instances  widely 
diffused,  but  it  is  far  more  commonly  localized.  Enlargement 
of  the  cervical  glands  is  most  common.  Enlargement  of  the 
mesenteric  glands  causes  tabes  mesenterica. 

Cervical  lymphadenitis  may  be  confused  with  lymphade- 
noma.     The    former,  as  a  rule,   first   appears   in  the   sub- 


TUBERCULOSIS  AND   SCROFULA.  1 45 

maxillary  triangle,  the  latter  in  the  occipital  or  inferior 
carotid  triangles.  Tuberculous  glands  weld  together,  they  are 
apt  to  remain  localized,  and  they  tend  to  suppurate.  They 
may  be  accompanied  by  other  tuberculous  manifestations. 
Lymphadenoma  from  the  start  affects  many  glands  in  several 
regions,  shows  no  tendency  to  suppurate,  and  is  accompanied 
by  great  debility  and  anaemia.  Malignant  gland-tumors  infil- 
trate adjacent  glands  and  other  structures,  binding  skin, 
muscles,  and  glands  into  one  firm  mass. 

Diag-nosis. — The  diagnosis  may  be  determined  by  purely 
clinical  facts.  It  may  require  the  use  of  the  microscope, 
cultivation  experiments,  or  inoculations.  In  a  suspected 
tuberculous  lesion  remove  a  portion  of  the  tissue  if  it  be 
accessible  (by  Mixter's  canula)  and  make  sections,  stains,  and 
cultivations.  If  no  bacilli  are  found,  inoculate  a  guinea-pig 
with  the  suspected  material.  If  it  be  tubercular,  the  pig  will 
have  miliary  tuberculosis  in  a  few  weeks. 

Prognosis. — The  prognosis  varies  with  age,  sex,  and  the 
situation  of  the  lesion.  Prognosis  is  best  in  children,  and  is 
better  in  males  than  in  females.  Tuberculosis  of  the  skin 
gives  a  fair  prognosis.  Tuberculous  adenitis  is  often  cured. 
Any  tuberculous  lesion  is,  however,  a  menace  to  the  organ- 
ism, and  tends  strongly  toward  recurrence. 

Treatment. — Surgically,  remove  infected  areas  which  are 
accessible.  Never  remove  only  part  of  a  focus.  Incomplete 
operations  are  apt  to  be  followed  by  diffuse  tuberculosis. 
Iodoform  used  locally  upon  or  in  tuberculous  areas  is  of  great 
value.  Tuberculous  glands  before  breaking  down  should  be 
rubbed  with  ichthyol  and  lanolin  or  with  mercurial  ointment. 
When  they  break  down  they  should  be  removed  or  opened, 
curetted,  and  packed.  The  rule  must  be  to  completely  dis- 
sect out  lymphatic  glands  which  fail  to  quickly  respond  to 
treatment.  Climate  is  of  very  great  importance.  Osier  sums 
up  climatic  necessities  as  "  pure  atmosphere,  equable  tem- 

10 


146  A   MANUAL    OF  SURGERY. 

perature,  and  maximum  amount  of  sunshine."  Open-air  life 
is  imperative.  The  patient  must  have  a  well-ventilated  sleep- 
ing-room, and  his  house  should  be  free  from  dampness. 
Nourishing  diet  is  essential.  To  gain  in  weight  is  a  constant 
aim.  Give  meat,  milk,  and  cod-liver  oil,  which  can  be  admin- 
istered in  capsules.  The  oil  is  poorly  borne  in  hot  weather, 
during  which  it  should  be  discontinued.  Advancing  doses  of 
creosote,  arsenic,  quinine,  and  stimulants  have  their  uses. 

Koch's  Tuberculin. — The  specific  treatment  by  Koch's 
tuberculin  or  paratoloid  has  excited  widespread  interest.  It 
has  not  fulfilled  the  expectations  which  many  entertained, 
but  does  benefit  some  cases,  notably  lupus.  The  trouble 
with  Koch's  tuberculin  is  that  it  often  causes  fever  and 
inflammation  to  a  dangerous  degree.  In  some  cases,  as 
Virchow  showed,  it  produces  acute  miliary  tuberculosis. 
Koch's  lymph  is  a  glycerin  extract  of  a  culture  of  tubercle 
bacilli,  and  the  usual  dose  is  I  milligramme,  given  hypoder- 
matically  into  the  back  by  Koch's  pistonless  syringe.  After 
it  has  been  used  for  a  time  the  dose  may  be  increased  to  10 
milligrammes,  or  even  much  more.  Bergmann  gave  I  gram. 
Koch's  lymph  causes  inflammation  and  necrosis  of  tubercu- 
lous tissue  by  the  action  of  certain  antitoxines.  Many  cases 
it  improves.  Some  cases  it  apparently  cures,  but  the  disease 
is  apt  to  return.  In  pulmonary  tubercle  it  must  not  be  given 
if  there  be  much  fever  or  extensive  consolidation.  Cheyne 
used  tuberculin  by  giving  two  or  three  doses  a  day  and 
increasing  the  dose.  It  is  best  to  associate  other  treatment 
with  the  lymph. 

Hunter  of  London  declares  that  Koch's  lymph  contains 
one  principle  which  causes  fever,  another  which  causes  in- 
flammation, and  a  third  which  produces  atrophy  of  tuber- 
culous foci  without  either  fever  or  inflammation.  This  third 
desirable  element  he  believes  he  has  isolated  in  what  is 
called  a  *'  derivative  of  tuberculin,"  a  modified  lymph.    Some 


RICKETS.  -       147 


remarkable  results  have  followed  the  use  of  this  material ;  its 
administration  seems  entirely  safe,  and  it  should  thoroughly 
and  carefully  be  tried  to  ascertain  its  true  rank  as  a  remedy. 


XIII.    RICKETS. 

Rickets  is  a  constitutional  disease  arising  during  the  early 
years  of  life  (the  first  two  or  three)  as  a  result  of  insufficient 
or  of  improper  diet  and  bad  hygienic  surroundings.  A  defi- 
ciency of  fat  and  phosphate  in  the  food  or  the  use  of  a  diet 
which,  by  inducing  gastro-intestinal  catarrh,  prevents  assimi- 
lation, causes  rickets.  The  disease  is  never  congenital,  the 
so-called  "  congenital  rickets "  being  sporadic  cretinism 
(Bowlby).     Figure  4  (PL   2)  shows  marasmic  rickets. 

Evidences  of  Rickets. — The  condition  is  one  of  general 
ill-health;  the  child  is  ill-nourished,  pallid,  flabby;  it  has 
attacks  of  diarrhoea  and  a  tumid  belly ;  it  is  disinclined  for 
exertion  and  has  a  capricious  appetite  ;  it  is  liable  to  night- 
sweats  and  night-terrors  ;  enlarged  glands  are  often  noted, 
the  teeth  appear  behind  time,  and  the  fontanelles  close  late. 
The  long  bones  become  much  curved,  the  upper  part  of  the 
chest  sinks  in,  curvature  of  the  spine  appears,  the  head  is 
large  and  the  forehead  bulges,  and  the  pelvis  is  distorted. 
Swelling  appears  in  the  articular  heads  of  long  bones,  beside 
the  epiphyseal  cartilages,  and  in  the  sternal  end  of  the  ribs, 
forming  in  the  latter  case  rhachitic  beads.  The  lesions  of 
rickets  are  due  to  an  imperfect  ossification  of  the  animal 
matter  which  is  prepared  for  bone-formation,  and  conse- 
quently to  softening  of  the  bones  which  causes  them  to 
bend.  The  swellings  at  the  articular  heads  are  due  to  pres- 
sure forcing  out  the  soft  bone  into  rings.  Rhachitic  children 
rarely  grow  to  a  full  size,  and  the  disease  is  responsible  for 
many  dwarfs.  Most  cases  recover  without  deformity,  but 
the  time  lost  during  the  period  when  active  development 


148  A   MANUAL    OF  SURGERY. 

should  have  gone  on  cannot  be  made  up,  and  some  slight 
deficiency  is  sure  to  remain. 

Treatment. — The  treatment  consists  in  open  air,  sunshine, 
salt-water  baths,  sea-air,  fresh  food  (milk,  cream,  and  meat- 
juice),  cod-liver  oil  especially,  syrup  of  the  iodide  of  iron, 
arsenic,  and  some  form  of  phosphorus. 

XIV.    CONTUSIONS   AND   WOUNDS. 

Contusions. — A  contusion  or  bruise  is  a  subcutaneous 
laceration,  the  skin  above  it  being  uninjured  (as  in  the 
abdomen)  or  damaged  with  a  surface-breach  (as  in  a  part 
overlying  bone),  blood  being  effused.  If  a  large  vessel  is 
damaged,  the  hemorrhage  is  large.  An  ecchyrnosis  is  diffuse 
hemorrhage  over  a  large  area;  a  hematoma  is  a  blood-tumor 
or  a  circumscribed  hemorrhage.  In  a  diffuse  hemorrhage 
the  coagulation  of  fibrin  induces  induration ;  the  serum  and 
leucocytes  are  absorbed  ;  the  red  blood-cells  disintegrate  and 
the  coloring  matter  is  widely  diffused  (suggillation) ;  and 
haemoglobin  is  changed  into  hsematoidin,  which  crystallizes. 
In  union  with  these  chemical  changes,  color-changes  ensue, 
the  part  being  at  first  red  and  then  becoming  purple,  black, 
green,  lemon,  and  citron.  A  haematoma  acts  as  an  irritant, 
inflammation  ensues  around  it,  and  it  is  encapsuled  by  em- 
bryonic tissue,  which,  by  organizing  into  fibrous  tissue,  forms 
a  blood-cyst  and  gradually  absorbs  the  fluid  blood,  the  cyst- 
contents  becoming  thicker  and  thicker.  A  fibrous  scar  may 
remain.  If  serum  is  not  absorbed,  haematoidin  forms  and 
the  fluid  becomes  clear.  A  haematoma  may  suppurate,  an 
abscess  forming. 

Symptoms. — The  symptoms  are  heat,  tenderness,  swell- 
ing, and  numbness  followed  by  pain.  Discoloration  appears 
quickly  in  superficial  contusions,  but  days  after  in  deep  ones  ; 
shock  and  loss  of  function  are  present  after  severe  contusions. 


CONTUSIONS  AND    WOUNDS.  1 49 

Treatment. — Obtain  reaction  from  the  shock.  Local  treat- 
ment consists  of  rest,  elevation,  and  compression  to  arrest 
bleeding,  antagonize  inflammation,  and  control  swelling. 
Cold  is  useful  early  in  a  case,  but  it  is  not  suited  to  severe 
contusions  or  to  contusions  in  the  debilitated  or  aged,  as  in 
such  cases  it  may  cause  gangrene.  Lead-water  and  laudanum 
and  iodine  may  be  used.  In  very  severe  contusions  employ 
heat  and  stimulation.  When  inflammation  is  subsiding  after 
a  contusion,  massage  and  ichthyol  should  be  ordered.  A 
contusion  should  never  be  opened  unless  hemorrhage  con- 
tinues, infection  takes  place,  or  a  lump  remains  for  some 
weeks.  For  persistent  bleeding  freely  lay  open  the  contu- 
sion, turn  out  clots,  ligate  vessels,  irrigate  with  corrosive- 
sublimate  solution,  insert  a  tube,  and  close.  If  gangrene  is 
feared,  use  iodine  locally,  and  if  a  slough  forms,  employ 
antiseptic  fomentations.  Constitutional  treatment  for  con- 
tusion is  the  same  as  that  for  inflammation. 

Wounds. — A  wound  is  a  breach  of  surface  continuity  by 
a  sudden  and  violent  mechanical  force.  Wounds  are  divided 
into  open  and  subcutaneous,  septic  and  aseptic,  contused, 
incised,  lacerated,  punctured,  gunshot,  and  poisoned. 

The  local  phenomena  of  wounds  are  pain,  hemorrhage, 
loss  of  function,  and  gaping  or  retraction  of  edges. 

Pain  is  due  to  the  injury  of  nerves,  and  it  varies  according 
to  the  situation  and  to  the  nature  of  the  injury.  It  is  influ- 
enced by  temperament,  excitement,  and  preoccupation.  It 
may  not  be  felt  at  all  at  the  time  of  the  injury.  At  first  it 
is  usually  acute,  becoming  later  dull  and  aching.  In  an  asep- 
tic wound  the  pain  is  slight,  but  in  an  infected  wound  it  is 
severe. 

Hemorrhage  varies  with  the  state  of  the  system,  the  vas- 
cularity of  the  part,  and  the  variety  of  injury. 

Loss  of  Function. — Depends  on  the  situation  and  extent  of 
the  injury. 


150  A   MANUAL    OF  SURGERY. 

Gaping  or  Retraction  of  Edges. — Due  to  tissue-elasticity. 

The  constitutional  condition  is  that  of  shock,  which  is  a 
sudden  depression  of  the  vital  powers  arising  from  an  injury 
or  a  profound  emotion  acting  on  the  nerve-centres  and  in- 
ducing vaso-motor  paresis,  the  blood  accumulating  in  the 
abdominal  vessels.  It  may  be  slight  and  transient,  it  may 
be  severe  and  prolonged,  and  it  may  even  produce  almost 
instant  death.  It  is  more  severe  in  men  than  in  women,  in 
the  nervous  and  sanguine  than  in  the  lymphatic,  in  those 
inured  to  suffering  than  in  those  who  are  strangers  to  illness. 
Injury  of  the  abdomen  produces  great  shock,  and  so  does 
damage  to  the  viscera,  the  urethra,  and  the  testicles.  Cere- 
bral concussion  is  a  form  of  shock  plus  other  conditions. 
Sudden  and  profuse  hemorrhage  causes  shock ;  so,  occa- 
sionally, does  anaesthetization. 

Symptoms. — The  symptoms  are  a  temperature  much 
below  normal ;  weak,  rapid,  and  compressible  pulse ;  cold, 
clammy,  or  profusely-perspiring  skin ;  shallow  respiration ; 
a  tendency  to  urinary  suppression  ;  consciousness  is  usually 
maintained,  but  there  is  an  absence  of  mental  originating 
power,  the  injured  person  answering  when  spoken  to,  but 
volunteering  no  statements  and  lying  with  partly-closed  lids 
in  any  position  in  which  he  may  have  been  placed.  If  de- 
lirium arises,  the  condition  is  very  grave  (delirious  shock). 
Pain  is  slightly  or  not  at  all  appreciated.  Vomiting  may,  as 
in  concussion,  presage  reaction.  Vomiting  after  a  consider- 
able time  in  shock  is  regurgitation,  and  is  a  bad  omen. 

Diagnosis. — Concealed  hemorrhage  is  hard  to  separate 
from  shock.  It  produces  impairment  of  vision  (retinal 
anaemia),  irregular  tossing,  frequent  yawning,  nausea,  and 
sometimes  convulsions.  In  shock  the  haemoglobin  is  unal- 
tered ;  in  hemorrhage  it  is  enormously  reduced  (Hare  and 
Martin).  In  hemorrhage  recurrent  attacks  of  syncope  are 
met  with.    Shock  and  hemorrhage  are  often  associated.    The 


CONTUSIONS  AND    WOUNDS.  I5I 

essential  characteristic  of  shock  is  sudden  onset,  which  sep- 
arates it  from  exhaustion. 

Treatment. — In  treating  shock  from  a  wound,  lower  the 
head,  apply  hot  bottles  and  hot  blankets,  and  give  hypo- 
dermatic injections  of  ether,  brandy,  strychnine,  digitalis,  or 
atropia.  A  turpentine  enema  is  useful.  Hot  coffee  or  other 
hot  fluids  should  be  given  by  the  mouth  and  rectum,  mustard 
be  placed  over  the  heart,  spine,  and  shins,  and  the  hypoder- 
moclysis  of  salines  be  practised.  If  shock  comes  on  during 
operation,  the  proceedings  must  be  hurried  or  even  be 
stopped.  Should  we  operate  during  shock  ?  Clearly,  no, 
except  for  the  purpose  of  arresting  hemorrhage.  Do  not, 
for  instance,  perform  an  amputation  in  shock,  but  arrest  hem- 
orrhage, asepticize,  and  bring  about  reaction  before  operating. 

Fat-embolism. — (See  Embolisin,  p.  124.) 

Fever. — (See  Fevers) 

Treatment  of  Wounds. — The  rules  for  treating  wounds 
are — (i)  arrest  hemorrhage ;  (2)  bring  about  reaction ;  (3) 
remove  foreign  bodies  ;  (4)  asepticize  ;  (5)  drain,  coaptate  the 
edges,  and  dress ;  and  (6)  secure  rest  to  the  part  and  combat 
inflammation.  Constitutionally,  allay  pain,  secure  sleep,  keep 
up  the  nutrition,  and  treat  inflammatory  conditions. 

Arrest  of  Hemorrhage. — To  arrest  hemorrhage  the  bleed- 
ing point  must  be  controlled  by  digital  pressure  until  ready 
to  be  grasped  with  forceps  ;  it  is  then  caught  up  and  tied 
with  catgut  or  aseptic  silk.  Slight  hemorrhage  stops  spon- 
taneously on  exposure  to  air,  and  moderate  hemorrhage 
ceases  after  the  vessels  are  clamped  for  a  time ;  an  injured 
vessel  of  some  size  must  be  ligated,  even  if  it  has  ceased  to 
bleed.  Capillary  oozing  is  checked  by  hot-water  compresses. 
If  a  large  artery  is  divided  in  a  limb,  apply  a  tourniquet 
before  li gating  (see    Wojc?ids  of  Vessels). 

Bringing' About  of  Reaction. — (See  Shock) 

Removal  of  Foreign  Bodies. — Remove  all  foreign  bodies 


152  A   MANUAL    OF  SURGERY. 

visible  to  the  eye  (splinters,  bits  of  glass,  portions  of  clothing, 
gun-wadding,  grains  of  dirt,  etc.)  with  forceps  and  a  stream 
of  corrosive-sublimate  solution.  In  a  lacerated  or  contused 
wound  portions  of  tissue  injured  beyond  repair  should  be 
regarded  as  foreign  bodies  and  be  removed  with  scissors. 

Cleaning  the  Wound. — To  clean  the  wound  scrub  the  area 
around  it  with  Johnson's  ethereal  soap  and  then  with  cor- 
rosive-sublimate solution  (i  :  looo).  If  the  surface  is  hairy, 
it  must  be  shaved.  The  wound  must  be  well  washed  out 
with  an  antiseptic  solution,  thus  getting  rid  of  blood-clots 
which  would  serve  to  separate  the  edges  and  favor  infection. 

Drainage,  Closure,  and  Dressing. — Superficial  wounds  re- 
quire no  special  drain,  as  some  wound-fluid  will  find  exit 
between  the  stitches  and  the  rest  will  be  absorbed.  A  large 
or  deep  wound  requires  free  drainage  for  at  least  twenty-four 
hours  by  means  of  a  tube,  strands  of  horse-hair,  silk,  or 
catgut,  or  bits  of  iodoform  gauze.  An  infected  wound  must 
invariably  be  drained.  Good  drainage  almost  compensates 
for  imperfect  antisepsis.  If  capillary  drains  be  employed, 
apply  a  moist  dressing.  Divided  nerves  and  tendons  must 
be  sutured.  Close  the  edges  with  silk  sutures  or  silkworm- 
gut  if  the  wound  is  deep  and  tension  is  inevitable.  Catgut 
is  used  for  superficial  wounds  and  for  those  where  tension 
is  slight.  The  interrupted  suture  is,  as  a  rule,  the  best. 
If  the  wound  is  infected,  dress  with  antiseptic  gauze  ;  or  with 
either  aseptic  or  antiseptic  gauze  if  it  is  not  infected.  Cover 
the  gauze  with  a  rubber  dam  to  diffuse  the  fluids.  Change 
the  dressings  in  twenty-four  hours,  or  sooner  if  they  become 
soaked  with  discharge.  After  this,  in  an  aseptic  wound,  the 
dressing  need  not  be  changed  for  days.  If  pus  forms,  open 
the  wound  at  once. 

Rest. — Severe  wounds  require  confinement  in  bed.  Band- 
ages, splints,  etc.  are  used  to  secure  rest.  The  methods  of 
combating  inflammation  have  previously  been  set  forth. 


CONTUSIONS  AND    WOLNDS.  1 53 

Constitutional  Treatment. — Bring  about  reaction  from  de- 
pression, but  prevent  undue  reaction.  Feed  the  patient  well, 
stimulate  him  if  necessary,  and  attend  to  the  bowels  and 
bladder.  Watch  the  temperature  as  the  danger-signal,  secure 
sleep,  and  allay  pain.  Look  out  for  complications,  namely, 
inflammation,  suppuration,  gangrene,  tetanus,  and  erysipelas. 

Incised  Wounds. — An  incised  wound  is  a  clean  cut  in- 
flicted by  an  edged  instrument.  Only  a  thin  film  of  tissue 
is  so  devitalized  that  it  must  die.  These  wounds  have  a 
splendid  chance  of  union  by  first  intention. 

Symptoms. — The  symptoms  of  incised  wounds  are  sharp 
pain  for  a  time,  followed  by  smarting,  profuse  bleeding,  and 
decided  retraction  of  the  edges. 

Treatment. — The  treatment  of  incised  wounds  is  accord- 
ing to  general  rules.  Do  not  use  styptics,  as  they  cause  a 
repugnant  clot,  produce  irritation,  and  favor  infection. 

Lacerated  and  Contused  "Wounds. — A  lacerated  wound 
is  a  tearing  apart  of  the  tissues ;  a  contused  wound  is  a 
crushing  and  pulpefying  of  tissues.  These  two  forms  are 
combined.  They  are  irregular,  contain  masses  of  partially- 
detached  tissue  and  blood-clots,  and  their  edges  are  cold 
and  discolored.     Such  wounds  tend  to  necrosis. 

Symptoms. — The  symptoms  are  excessive  shock,  slight 
hemorrhage,  and  only  a  moderately  dull  pain.  Reactionary 
and  secondary  hemorrhages  are  common.  Infection  is  liable 
to  occur,  and  more  or  less  sloughing  is  bound  to  ensue. 

Treatment. — Anv  damaged  vessel,  whether  it  bleeds  or 
not,  must  be  tied,  the  devitalized  tissues  cut  a\va\',  and  for- 
eign bodies  removed.  Asepticize  with  great  care  and  secure 
thorough  drainage,  making  very  usually  counter-openings. 
In  dressing,  put  iodoform  in  the  wound  and  close  it  par- 
tially. Watch  for  bleeding  during  reaction.  When  slough- 
ing begins,  use  antiseptic  fomentations.  A  brnsh-biirn,  which 
is  a  contused-lacerated  wound  due  to  friction,  requires  the 


154  ^    MANUAL    OF  SURGERY. 

use  of  an  antiseptic  poultice  until  the  slough  is  cast  off.  In 
badly-lacerated  wounds  and  crushes  it  is  often  necessary  to 
amputate. 

Punctured  wounds  are  wounds  made  by  pointed  instru- 
ments. A  punctured  wound  is  usually  deep,  it  closes  partlj^ 
after  withdrawal  of  the  instrument,  blood-clot  and  wound- 
fluids  cannot  get  exit,  and  infection  is  certain  if  the  instru- 
ment carries  microbes.  Large-sized  foreign  bodies  may  be 
driven  in  or  a  portion  of  the  instrument  may  break  off 
Arrow-wounds  are  punctured  and  incised. 

Symptoms. — In  punctured  wounds  the  pain  is  rarely 
severe,  but  hemorrhage  is  slight  unless  a  large  vessel  be 
wounded.  Infection  is  apt  to  ensue.  Varicose  aneurysm 
may  be  caused. 

Treatment. — In  treating  punctured  wounds  incise  to  the 
depth  of  the  puncture,  stop  the  hemorrhage,  asepticize,  and 
drain.  An  arrow  should  never  be  pulled  out,  but  should 
be  pushed  through  or  cut  down  to  by  enlarging  the  wound. 

Gunshot  wounds  are  injuries  inflicted  by  projectiles,  such 
as  shot  and  bullets,  driven  by  explosives.  If  a  bullet  just 
grazes  a  surface,  a  friction-burn  results ;  if  it  enters  the  tis- 
sues, it  produces  a  punctured-contused-lacerated  wound ;  if  it 
strikes  the  tissue,  but  fails  to  enter,  it  causes  a  contusion. 
If  a  bullet  enters  a  cavity  or  an  organ  and  does  not  emerge, 
it  produces  a  penetrating  wound ;  if  it  does  emerge,  it  is  a 
perforating  wound.  Bullets  are  very  apt  to  carry  a  foreign 
body  into  the  tissues  (clothing,  wadding,  etc.).  The  wound 
of  entrance  is  round,  smooth,  and  depressed,  and  is  smaller 
than  the  ball,  because  the  skin  stretches  as  the  bullet  strikes  it 
and  contracts  again  after  it  has  passed.  The  skin  around  the 
wound  of  entrance  is  discolored  by  the  ball,  or,  if  the  discharge 
took  place  near  the  victim,  it  is  blackened  by  the  gunpowder. 
A  wound  of  entrance  larger  than  the  ball  means  the  entrance 
with  the  projectile  of  some  foreign  body.     The  wound  of 


CONTUSIONS  AND    WOUNDS.  1 55 

exit,  if  one  exists,  is  irregular,  everted,  and  larger  than  the 
bullet  (especially  so  if  a  round  ball  was  used).  Hemorrhage 
is  slight  unless  a  large  vessel  is  opened,  pain  varies,  and  shock 
is  severe.  Dense  fascia  resists  a  ball  strongly,  often  deflect- 
ing it,  and  is  irregularly  torn  when  the  missile  passes,  pre- 
senting fringes  which  interfere  with  probing  and  drainage. 
Tendons  are  generally  pushed  away.  Vessels  are  usually 
pushed  aside,  but  they  may  be  divided.  If  pushed  aside, 
the  damage  done  them  is  apt  to  produce  sloughing  and 
secondary  hemorrhage  or  cause  an  aneurysm  to  develop. 

Dias'iiosis. — To  diagnosticate  the  extent  and  nature  of  a 
gunshot  wound,  put  the  parts  in  the  position  they  were  in 
when  injured;  ascertain  the  direction  of  the  ball's  course, 
the  size  and  nature  of  the  weapon,  and  its  distance  away 
when  fired.  Examine  the  clothing  to  see  if  any  part  was 
carried  in.     Do  not  probe  without  a  special  indication. 

Treatment. — To  treat  a  gunshot  wound,  bring  about  re- 
action. If  hemorrhage  be  severe,  take  a  knife  and  enlarge 
the  wound,  find  the  bleeding  vessel,  and  secure  it.  Thor- 
oughly cleanse  the  wound  and  adjacent  parts  before  handling. 
Do  not  explore  for  the  ball  unless  sure  that  it  has  carried  in 
with  it  septic  foreign  bodies,  unless  its  presence  interferes 
with  repair,  unless  it  is  in  or  near  a  vital  region  (as  the 
brain),  or  unless  it  is  necessary  to  determine  the  position  of 
the  ball  in  order  to  decide  the  question  of  amputation  or 
resection.  The  best  probe  is  the  finger.  There  may  be 
used  Fluhrer's  aluminium  probe,  Nelaton's  porcelain  probe, 
the  stem  of  a  clay  pipe,  or  a  bit  of  pine  wood,  the  last  three 
of  which  stain  with  lead  and  will  indicate  whether  the  hard 
body  is  bone  or  a  bullet.  Girdner's  telephonic  probe  can 
be  tried  if  we  wish  to  locate  the  ball.  If  any  chance 
of  success  exists,  try  to  get  primary  union  by  antisepsis 
and  rest.  This  union  will  usually  fail  because  of  infec- 
tion at  the  time  of  the  injury  and  the  inevitable  necrosis 


156  A   MANUAL    OF  SURGERY. 

of  the  compressed  and  damaged  tissue.  In  any  case  use 
rigid  antisepsis  and  watch  for  compHcations.  Infection  calls 
for  enlargement  of  the  wound  and  a  counter-opening.  For 
removing  a  ball  numerous  forceps  have  been  devised. 

Resection. — Resection  is  sometimes  demanded  for  the 
splintering  of  a  joint. 

Amputation  is  sometimes  demanded  because  of  great  injury 
to  the  soft  parts  (as  by  a  shell-fragment),  the  splintering  of  a 
bone,  injury  of  a  joint,  damage  to  the  chief  vessels  or  nerves, 
or  the  destruction  of  a  considerable  part  of  a  limb.  Per- 
form a  primary  amputation  if  possible,  and  make  the  flaps 
through  tissue  that  will  not  slough.  In  civil  practice,  with 
careful  antisepsis,  more  questionable  tissue  can  be  admitted 
into  a  flap  than  in  military  practice,  where  transportation  may 
be  necessary  and  antisepsis  be  imperfect  or  wanting. 

Poisoned  -wounds  are  those  in  which  a  poison  is  intro- 
duced. This  poison  may  be  microbic  and  capable  of  self- 
multiplication,  or  it  may  be  chemical,  and  hence  incapable 
of  multiplication.  There  are  three  classes  of  poisoned  wounds :  ^ 
(r)  mixed  infection,  as  septic  wounds,  dissection-wounds,  and 
malignant  oedema ;  (2)  chemical  poison,  such  as  snake-bites 
and  insect-stings  ;  and  (3)  microbic  infection,  such  as  rabies, 
glanders,  etc. 

Septic  wounds  are  those  which  suppurate  or  slough. 
Open  septic  wounds  freely  for  drainage,  curette  or  cut  away 
hopelessly  damaged  tissue,  wash  with  peroxide  of  hydrogen 
and  then  with  corrosive  sublimate,  dust  in  iodoform,  and 
either  use  a  drainage-tube  or  pack  with  iodoform  gauze. 
Watch  the  temperature  for  evidences  of  general  infection  or 
intoxication.  Stimulate  and  secure  good  nourishment,  rest, 
and  sleep. 

Dissection-wounds  are  simple  examples  of  infected 
wounds,  and  they  present  nothing  peculiar  except  virulence. 
^  American    Text-book  of  Surgery. 


CONTUSIONS  AND    WOUNDS.  1 57 

They  affect  butchers,  cooks,  surgeons  who  cut  themselves  in 
operating  on  a  poisoned  area,  those  who  make  post-mortems, 
and  those  who  dissect.  A  dissection-wound  inflicted  while 
working  on  a  body  injected  with  chloride  of  zinc  possesses 
but  few  elements  of  danger  unless  the  health  of  the  student 
is  much  broken  down.  Post-mortems  are  peculiarly  dano-er- 
ous  when  the  subject  has  died  of  some  septic  process. 
When  a  wound  is  inflicted  while  dissecting,  wash  it  under  a 
strong  stream  of  water,  suck  it  to  make  the  blood  run,  lay 
it  open  if  it  be  a  puncture,  swab  it  out  with  pure  carbolic 
acid,  and  dress  it  with  iodoform  and  gauze.  If  infection 
shows  itself,  it  must  be  treated  as  any  other  infected  wound. 

Malignant  oedema  or  gangrenous  emphysema  arises,  as 
a  rule,  after  punctures.  It  is  due  to  a  specific  bacillus  which 
produces  great  oedema,  and  to  secondary  infection  with  putre- 
factive organisms. 

Symptoms. — The  symptoms  are  oedema,  the  fluid  being  dis- 
tinctly bloody,  followed  by  rapidly-diffusing  gangrene  which 
is  surrounded  by  a  zone  of  oedematous  tissue  that  crepitates 
under  pressure  because  it  contains  gases  of  putrefaction.  The 
zone  of  oedema  is  covered  with  blebs  which  contain  thin, 
putrid,  reddish  matter.  The  constitutional  condition  is  one 
of  septicaemia.     Death  occurs,  as  a  rule,  in  a  {q.^  days. 

Treatment. — To  treat  malignant  oedem.a,  if  it  affect  a  limb, 
amputate  at  once,  high  up.  If  it  affect  some  other  part, 
excise,  use  the  actual  cautery,  and  dress  antiseptically.  Stim- 
ulate very  freely. 

Stings  and  Bites  of  Insects  and  Reptiles  :  Stings  of  Bees 
and  Wasps. — A  bee's  sting  consists  of  two  long  lances  within 
a  sheath  with  which  a  poison-bag  is  connected.  The  wound 
is  made  first  by  the  sheath,  the  poison  then  passes  in,  and 
the  two  lances,  moving  up  and  down,  deepen  the  cut.  The 
barbs  on  the  lances  make  it  difficult  to  rapidly  withdraw  the 
sting,  which   may  be   broken   off  and   remain  in  the   flesh. 


158  A   MANUAL    OF  SURGERY. 

Besides  bees,  hornets,  yellow-jackets,  and  other  wasps  pro- 
duce painful  stings.  These  stings  rarely  produce  any  trouble 
except  pain  and  swelling.  In  some  rare  cases  a  bee-sting 
is  fatal ;  persons  have  been  stung  to  death  by  a  great  number 
of  these  insects. 

Symptoms. — If  general  symptoms  ensue,  they  appear  rap- 
idly and  consist  of  great  prostration,  vomiting,  purging,  and 
delirium  or  unconsciousness.  These  symptoms  may  dis- 
appear in  a  short  time,  or  they  may  end  in  death  from  heart- 
failure.    Stings  of  the  mouth  may  cause  oedema  of  the  glottis, 

Trcatuicjit. — To  treat  a  bee-sting,  extract  the  sting  if  it  be 
broken  off,  and  apply  locally  a  Solution  of  washing-soda, 
tincture  of  arnica,  iodine,  or  lead-water  and  laudanum.  If 
constitutional  symptoms  appear,  stimulate. 

Other  Insect-bites  and  Sting's. — The  mandibles  of  a  spider 
are  terminated  by  a  movable  hook  which  has  an  opening 
for  the  emission  of  poison.  The  bite  of  large  spiders  is  pro- 
ductive of  inflammation,  swelling,  weakness,  and  even  death. 
The  bite  of  the  poisonous  spider  of  New  Zealand  produces 
a  large  white  swelling  and  great  prostration ;  death  may 
ensue,  or  the  victim  may  remain  in  a  depressed,  enfeebled 
state  for  weeks  or  even  for  months.  The  tarantula  is  a  much- 
dreaded  spider.  A  scorpion  has  in  its  tail  a  sting,  and  a 
scorpion's  sting  produces  great  prostration,  delirium,  vomit- 
ing, diaphoresis,  vertigo,  headache,  local  swelling,  and  burning 
pain,  followed  often  by  suppuration,  or  even  by  gangrene  and 
fever.  Centipedes  must  be  of  large  size  to  be  formidable 
to  man,  and  the  symptoms  arising  from  their  stings  are  usu- 
ally only  local. 

Treatment. — Tie  a  fillet  above  the  bitten  point ;  make  a 
crucial  incision,  favor  bleeding,  and  swab  out  th^  wound  with 
pure  carbolic  acid  or  some  caustic  or  antiseptic  (if  in  the 
wilds,  burn  with  fire  or  gunpowder) ;  dress  antiseptically  if 
possible,  and  stimulate  as  constitutional   symptoms  appear, 


CONTUSIONS  AND    WOUNDS.  1 59 

slowly  loosening  the  ligature.  Chloroform  stupes  and  ipecac 
poultices  are  recommended,  also  puncture  with  a  needle  and 
rubbing  in  3  parts  of  chloral  and  i  part  of  camphor/ 

Snake-bites. — The  poisonous  snakes  of  America  com- 
prise the  copperheads,  water-moccasins,  rattlesnakes,  and 
vipers.  There  is  also  a  poisonous  lizard.  The  symptoms 
of  snake-bite  are  similar  whether  it  is  the  bite  of  an  Indian 
cobra  or  of  an  American  rattler,  and  they  depend  upon 
the  dose  of  poison  introduced.  Poison  injected  into  a  vein 
may  prove  almost  instantly  fatal.  The  poison  is  not  ab- 
sorbed by  the  sound  mucous  membranes.  It  is  discharged 
through  the  hollow  fangs  of  the  reptile  by  contractions  of 
the  muscles  of  the  poison-bag.  In  most  varieties  of  snakes 
the  teeth  lie  along  the  back  of  the  mouth  and  are  only 
erected  when  the  reptile  strikes.  The  poison  contains  proteid 
constituents,  globulins,  and  peptones  (Mitchell  and  Reichert), 
and  probably  toxic  animal  alkaloids  (Brieger). 

Svmptonis. — The  symptoms  are — pain,  soon  becoming  in- 
tense ;  mottled  swelling  of  the  bitten  part,  which  swelling 
may  be  enormous,  and  which  is  due  to  oedema  and  extrava- 
sation  of  blood,  and  assumes  a  purpuric  discoloration.  There 
may  be  complete  consciousness,  or  there  may  be  lethargy, 
stupor,  or  coma.  Some  cases  present  spasms.  The  general 
symptoms  are  those  of  profound  shock,  w'hich  may  present 
delirium  (delirious  shock).  Death  may  arise  from  paralysis 
of  the  heart,  and  may  occur  in  about  five  hours,  but  as  a  rule 
it  is  postponed  for  a  number  of  hours.  If  death  is  deferred 
many  hours,  profound  sepsis  comes  upon  the  scene,  with 
glandular  enlargement,  suppuration,  and  sometimes  gangrene. 

Treatment. — Cases  of  snake-bite  must,  as  a  rule,  be  treated 
without  proper  appliances.  Prof  Gross  related  that  he  had 
seen  an  army  officer  blow  off  his  finger  with  a  pistol  the 
moment  it  was  struck,  and  thus  escape  poisoning.     For  bit- 

^  Bauerjie,  in  the  Lancet. 


l6o  A   MANUAL    OF  SURGERY. 

ten  fingers  or  toes  this  treatment  would  be  wise.  In  general, 
the  rules  are  to  twist  several  fillets  at  different  levels  above 
the  bite,  to  excise  the  bitten  area,  to  suck  or  cup  it  if  pos- 
sible, and  to  cauterize  it  by  a  pure  acid  or  by  heat.  An 
expedient  among  hunters  is  to  cauterize  by  pouring  gun- 
powder on  the  excised  area  and  applying  a  spark,  or  by  lay- 
ing a  hot  ember  on  the  wound.  When  a  hot  iron  is  available, 
use  it.  The  fillets  are  not  to  be  removed  suddenly,  and 
they  had  best  be  kept  on  for  some  time.  Remove  the  highest 
constricting  band  first ;  if  no  symptoms  come  on  after  a 
time,  remove  the  next,  and  so  on ;  if  symptoms  appear, 
reapply  the  fillet.  The  constitutional  treatment  is  expressed 
in  one  word :  stimulate.  Our  only  hope  is  in  large  doses 
of  alcohol,  and,  if  they  can  be  obtained,  ammonia,  ether, 
strychnine,  or  digitalis  hypodermatically  administered.  Mor- 
phia can  be  given  for  pain.  There  is  no  specific  for  snake- 
poison.  Hypodermatic  injections  in  the  area  adjacent  to  the 
bite  of  a  I  per  cent,  solution  of  the  permanganate  of  potash 
are  commended  by  some.  Halford  of  Australia  praises  the 
intravenous  injection  of  ammonia  (lO  TTL  of  strong  ammonia 
in  20  TTL  of  water).  If  a  man  is  bitten  by  a  large  and  deadly 
snake,  the  surgeon,  if  one  is  at  hand,  should  at  once  ampu- 
tate well  above  the  bite.^ 

Anthrax  (malignant  pustule,  charbon,  wool-sorters'  dis- 
ease, Milzbrand,  or  splenic  fever)  is  a  term  used  by  some  as 
synonymous  with  carbuncle,  but  it  is  not  here  so  employed. 
Anthrax,  when  seen  among  men,  is  a  disease  caught  in  some 
manner  from  an  animal  with  splenic  fever.  It  may  be  caught 
by  working  around  diseased  animals,  by  handling  or  tanning 
their  hides,  by  sorting  their  hair  or  wool ;  it  may  be  con- 
veyed by  eating  infected  meat  or  by  drinking  infected  milk. 
Flies  may  carry  the  poison. 

Forms  of  Anthrax. — There  are  two  forms  of  the  disease 

^  Charters  James  Symonds,  in  Heath's  Dictionary. 


CONTUSIONS  AND    WOUNDS.  l6l 

— anthrax  carbuncle  and  anthrax  oedema.  The  external  form 
presents  a  papule  with  a  red  base ;  the  papule  becomes  a 
vesicle  which  contains  bloody  serum  ;  the  vesicle  bursts  and 
dries,  the  base  of  it  swells  and  enlarges,  other  vesicles  appear 
in  circles  around  it,  and  there  is  developed  an  **  anthrax  car- 
buncle "  which  shows  a  black  or  purple  elevation  with  a 
central  depression  surrounded  by  one  or  more  rings  of 
vesicles.  Pain  is  trivial.  Lymphatic  enlargements  occur. 
In  loose  connective  tissue  the  lesion  may  be  anthrax  oedema, 
a  spreading  livid  oedema  followed  by  blebs  and  even  by 
gangrene.  The  constitutional  symptoms  may  rapidly  follow 
the  local  lesion,  but  may  be  deferred  for  a  week  or  more. 
The  patient  feels  depressed,  has  obscure  aches  and  pains, 
and  is  feverish,  but  usually  keeps  about  for  a  short  period. 
After  a  time  he  is  apt  to  develop  rigors,  high  irregular  fever, 
.sweats,  acute  fugitive  pains,  diarrhoea,  delirium,  typhoid 
exhaustion,  dyspnoea,  cough,  and  cyanosis.  The  local  car- 
buncle of  anthrax  is  distincruished  from  ordinarv  carbuncle 
by  the  central  depression,  the  adherent  eschar,  the  absence 
of  tenderness,  and  the  absence  of  suppuration  of  the  first, 
as  contrasted  with  the  elevated  centre,  the  multiple  foci  of 
suppuration  and  sloughing,  and  the  acute  pain  of  the  second. 
Anthrax  oedema  differs  from  cellulitis  in  the  absence  of  all 
tendency  to  form  pus,  and  from  malignant  oedema  by  the 
greater  tendency  of  the  latter  to  result  in  gangrene.  If 
anthrax  has  a  visible  lesion  and  the  constitutional  symptoms 
are  slight  or  absent,  the  chance  of  cure  is  good. 

Treatment. — If  a  person  is  wounded  by  an  object  sus- 
pected of  carrying  the  infection,  cauterize  the  wound  with 
the  hot  iron.  A  malignant  pustule  should  be  entirely  ex- 
cised and  the  wound  mopped  out  with  pure  carbolic  acid, 
or  burnt  with  the  hot  iron  and  afterward  dressed  with  wet 
bichloride-of-mercury  gauze  which  is  covered  with  an  ice- 
bag.  Another  plan  is  to  make  crucial  incisions  through  the 
11 


1 62  A   MANUAL    OF  SUJ^GERY. 

lesion,  to  mop  out  with  pure  carbolic  acid,  and  to  inject 
around  and  in  the  pustule  carbolic  acid  (i  :  lo)  every  six 
hours  until  the  disease  abates  or  toxic  symptoms  appear. 
The  adherent  eschar  is  subsequently  gotten  away  by  anti- 
septic poultices.  Constitutional  treatment  is  sustaining  and 
stimulating. 

Hydrophobia,  Rabies,  or  Lyssa. — Hydrophobia  is  a  spas- 
modic and  paralytic  disease  due  to  infection  through  a  wound 
with  the  virus  from  a  rabid  animal.  The  animal  may  be  a 
dog,  a  cat,  a  wolf,  a  fox,  or  a  horse.  Roux  estimates  that 
about  14  per  cent,  of  the  people  bitten  by  mad  animals  develop 
the  disease.  If  the  bite  is  on  an  exposed  part,  it  is  far  more 
apt  to  cause  rabies  than  if  the  teeth  pass  through  clothing. 
Hydrophobia  is  always  fatal.  The  saliva  is  the  usual  vehicle 
of  contagion,  but  other  fluids  and  tissues  contain  it,  espe- 
cially the  brain  and  cord. 

Symptoms. — The  period  of  incubation  of  hydrophobia  is 
from  a  few  weeks  to  two  years.  The  initial  symptoms  are 
mental  depression,  anxiety,  headache,  malaise,  and  often  pain 
or  even  congestion  in  the  cicatrix,  which  symptoms  are 
quickly  followed  by  a  general  hyperaesthesia,  pharyngeal 
spasms,  dyspnoea  from  laryngeal  spasms,  and  constant  attempts 
to  expectorate  thick  mucus  which  forms  because  of  congestion 
of  the  air-passages.  Attempts  at  swallowing,  as  well  as  lights 
and  noises,  tend  to  bring  on  spasms,  hence  the  fear  of  liquids 
(there  is  spasm  from  attempts  at  swallowing  or  from  thinking 
of  the  act).  The  entirebody  may  be  thrown  into  clonic  spasms, 
but  there  is  no  tonic  spasm.  The  mind  is  usually  clear, 
although  during  the  periods  of  excitement  there  may  be 
maniacal  furor  with  hallucinations  which  pass  away  in  the 
stage  of  relaxation.  The  temperature  is  moderately  elevated 
(101°  to  103°  or  higher).  This  spasmodic  stage  lasts  from 
one  to  three  days,  and  the  patient  may  die  during  this  period 
from  exhaustion  or  from  asphyxia.     If  he  lives  through  this 


CONTUSIONS  AND    WOUNDS.  1 63 

period,  the  convulsions  gradually  cease,  the  power  of  swal- 
lowing returns,  and  the  patient  succumbs  to  exhaustion  in 
less  than  twenty-four  hours,  or  he  develops  ascending  paral- 
ysis which  soon  causes  cardiac  and  respiratory  failure. 

In  hydrophobia  death  is  inevitable.  Those  cases  in  which 
it  is  alleged  that  recovery  ensued  were  not  true  hydro- 
phobia, but  hysteria.  Wood  says  that  in  hysteria,  especially 
among  boys,  "beast-mimicry"  is  common,  the  sufferer  snarl- 
ing like  a-  dog,  and  in  the  form  known  as  "  spurious  hydro- 
phobia," in  which  there  may  or  may  not  be  convulsion,  there 
is  a  dread  of  water,  emotional  excitement,  snarling,  and 
attempts  to  bite  the  bystanders  (in  genuine  hydrophobia  no 
attempts  are  made  to  bite  and  no  such  sounds  are  uttered 
as  are  made  by  a  dog). 

Lyssa  is  separated  from  lockjaw  by  the  spasms  of  the 
lar\mx  and  the  absence  of  tonic  spasms  in  the  former,  as 
contrasted  with  the  spasms  of  muscles  of  mastication  and 
the  tonic  spasms  with  clonic  exacerbations  of  lockjaw. 

Treatment. — When  a  person  is  bitten  by  a  supposed  rabid 
animal,  apply  constriction  above  the  wound  if  possible,  ex- 
cise, and  burn  with  the  hot  iron.  Send  the  patient  to  a 
Pasteur  institute  at  once,  that  he  may  be  given  preventive 
inoculations  of  an  emulsion  made  from  the  dried  spinal  cords 
of  hydrophobic  rabbits  (attenuated  virus).  The  value  of  this 
plan  seems  definitely  established.  In  the  paroxysm  the  treat- 
ment is  palliative,  and  cannot  be  curative.  Keep  the  patient 
in  a  dark,  quiet  room,  relieve  thirst  by  enemata,  saturate 
with  morphia,  and  in  the  paroxysms  anaesthetize. 

Glanders,  Farcy,  or  Equinia. — Glanders  is  an  infectious 
eruptive  fever  occurring  in  horses  and  communicable  to  man. 
If  the  nodules  occur  in  a  horse's  nares,  we  call  the  disease 
"glanders;"^  if  beneath  his  skin,  it  is  termed  "  farcy."  This 
disease  is  due  to  the  bacillus  of  Loffler,  and  is  communi- 
cated  to   man   through    an  abraded    surface   or  a   mucous 


164  ^   MANUAL    OF  SURGERY. 

membrane  (Osier).  The  characteristic  lesions  are  infective 
granulomata  which  in  the  nose  form  ulcers  and  under  the 
skin  develop  abscesses. 

Acute  and  Chrofiic  Glanders. — In  acute  glanders  there 
is  septic  inflammation  at  the  point  of  inoculation ;  nodules 
form  in  the  nose,  and  ulcerate ;  there  is  profuse  nasal  dis- 
charge ;  the  glands  of  the  neck  enlarge ;  there  are  fever  and 
an  eruption  like  small-pox  on  the  face  and  about  the  joints 
(Osier).  Acute  glanders  is  always  fatal.  Chronic  glanders 
lasts  for  months,  is  rarely  diagnosticated,  being  mistaken  for 
catarrh,  and  is  often  recovered  from.  Diagnosis  is  made  by 
injecting  a  guinea-pig  with  the  nasal  mucus. 

Acute  and  Chronic  Farcy. — Acute  farcy  appears  from 
a  skin-inoculation ;  it  begins  as  an  intense  inflammation, 
from  w^hich  run  out  inflamed  lymphatics  that  present  nodules 
or  "  farcy-buds."  Abscesses  form.  There  are  joint-pain  and 
the  constitutional  symptoms  of  sepsis,  but  no  involvement 
of  the  nares.  Chronic  farcy  may  last  for  months.  In  it 
nodules  occur  upon  the  extremities,  which  nodules  break 
down  into  abscesses  and  eventuate  in  ulcers  resembling 
those  of  tuberculosis. 

Treatment. — In  treating  this  disease  the  point  of  infection 
is  at  once  to  be  incised  and  cauterized.  Open  the  abscesses, 
swab  out  with  pure  carbolic  acid,  and  dress  antiseptically. 
Give  stimulants  and  nourishing  diet.  Diseased  horses  ought 
at  once  to  be  killed  and  their  stalls  torn  out  and  purified. 

Actmomycosis  is  an  infectious  disorder  characterized  by 
chronic  inflammation,  and  is  due  to  the  presence  in  the  tis- 
sues of  the  actinomyces  or  ray-fungus.  This  disease  occurs 
in  cattle  (lumpy  jaw)  and  in  pigs,  and  can  be  transmitted  to 
man,  apparently  by  the  food.  At  the  point  of  inoculation 
(which  is  usually  about  the  mouth)  arises  an  infective  granu- 
loma, around  which  inflammation  of  connective  tissue  occurs, 
suppuration  eventually  taking  place. 


SYPHILIS.  165 

Symptoms. — The  surgeon  may  see  the  lesion  in  the  jaw 
(the  enlargement  resembling  an  abscess  or  sarcoma),  on  the 
tongue,  and  on  the  skin  (resembling  cutaneous  tuberculosis). 
Pulmonary  actinomycosis  presents  fever,  cough,  and  wasting, 
the  symptoms  being  usually  one-sided  and  the  fungus  being 
found  in  the  expectoration.  Cerebral  actinomycosis  can  occur. 
Osier  says  the  disease  is  a  chronic  pyaemia  with  the  fungus 
existing  in  the  pus. 

Treatment. — The  treatment  consists  in  thoroughly  extir- 
pating the  growth  as  we  would  a  malignant  tumor.  Open, 
curette,  and  cauterize  abscesses  and  sinuses.  Remove  dead 
bone.     Iodide  of  potash  has  cured  cases. 


XV.    SYPHILIS. 

Definition. — Syphilis  is  a  chronic  infectious,  and  some- 
times hereditary,  constitutional  disease.  Its  first  lesion  is 
an  infecting  area  or  chancre,  which  is  followed  by  lym- 
phatic enlargements,  eruptions  upon  the  skin  and  mucous 
membranes,  affections  of  the  appendages  of  the  skin  (hair 
and  nails),  "  chronic  inflammation  and  infiltration  of  the 
cellulo-vascular  tissue,  bones,  and  periosteum  "  (White),  and, 
later,  often  by  gummata.  This  disease  is  probably  due  to 
a  microbe,  but  Lustgarten's  bacillus  has  not  been  proved  to 
be  the  one.  One  fact  against  its  being  the  cause  is  its  pres- 
ence in  the  non-contagious  late  gummata.  White  quotes 
Finger  in  his  assumption  that  syphilitic  fever  is  due  to 
absorption  of  ptomaines ;  that  the  eruptions  of  skin  and 
mucous  membranes  in  the  secondary  stage  arise  from  local 
deposit  and  multiplication  of  the  virus  ;  that  many  secon- 
dary symptoms  result  from  nutritive  derangement  caused  by 
tissue-products  passing  into  the  circulation ;  that  the  virus 
exists  in  the  body  after  the  cessation  of  secondary  symptoms  ; 


1 66  A   MANUAL    OF  SURGERY. 

and  that  it  may  die  out  or  may  awaken  into  activity,  pro- 
ducing "  reminders." 

During  the  primary  and  secondary  stages  fresh  poison 
cannot  infect,  and  this  is  true  for  a  time  after  the  disappear- 
ance of  secondary  symptoms.  Immunity  in  the  primary 
stage  is  due  to  products  absorbed  from  the  infected  area. 
Colles's  immunity  is  that  acquired  by  mothers  who  have 
borne  syphihtic  children,  but  who  themselves  show  no  sign 
of  the  disease.  Profeta's  immunity  is  the  immunity  against 
infection  possessed  by  many  healthy  children  born  of  syph- 
ilitic parents.  Tertiary  syphilitic  lesions  are  not  due  to  the 
poison  of  syphilis,  but  to  tissue-products  from  the  action  of 
that  poison.  Tertiary  syphilis  is  not  transmissible,  but  it 
secures  immunity. 

Transmission  of  Syphilis. — This  disease  can  be  trans- 
mitted— (i)  by  contact  with  the  tissue-elements  or  virus — 
acquired  syphilis  ;'  and  (2)  by  hereditary  transmission — Jiered- 
itary  syphilis.  The  poison  cannot  enter  through  an  intact 
epidermis  or  epithelial  layer,  and  abrasion  or  solution  of 
continuity  is  requisite  for  infection.  Syphilis  is  usually,  but 
not  always,  a  venereal  disease.  It  may  be  caught  by  infec- 
tion of  the  genitals  during  coition,  by  infection  of  the  tongue 
or  lips  in  kissing,  by  smoking  poisoned  pipes,  by  drinking 
out  of  infected  vessels,  or  by  beastly  practices.  The  initial 
lesion  of  syphilis  may  be  found  on  the  finger,  forehead,  eye- 
lid, lip,  tongue,  cheek,  palate,  anus,  nipple,  etc.  A  person 
may  be  a  host  for  syphilis,  carry  it,  give  it  to  another,  and 
yet  escape  it  himself  (a  surgeon  may  carry  it  under  his  nails, 
and  a  woman  may  lodge  it  in  her  vagina).  Syphilis  can  be 
transmitted  by  vaccination  with  human  lymph  v;hich  con- 
tains the  pus  of  a  syphilitic  eruption  or  the  blood  of  a 
syphilitic  person.  Vaccine  lymph,  even  after  passage  through 
a  person  with  pox,  will  not  convey  syphilis  if  it  is  free  from 
blood  and  the  pus  of  specific  lesions;  it  is  not  the  lymph 


SYPHILIS.  167 

that  poisons,  but  some  other  substance  which  the  lymph 
may  carry. 

Syphilitic  Stages. — SyphiHs  was  divided  by  Ricord  into 
three  stages:  {\)  \\\^  primary  stage — chancre  and  indolent 
bubo ;  (2)  the  secondary  stage — disease  of  the  upper  layer 
of  the  skin  and  mucous  membranes;  and  (3)  the  tertiary 
stage — affections  of  connective  tissues,  bones,  fibrous  and  se- 
rous membranes,  and  parenchymatous  organs.  This  division, 
which  is  useful  clinically,  is  still  largely  employed,  but  it  is 
not  so  sharp  and  distinct  as  was  believed  by  Ricord  ;  it  is  only 
artificial.  For  instance,  ozoena  may  develop  during  a  second- 
ary eruption,  and  bone  disease  may  appear  early  in  the  case. 

Syphilitic  Periods. — White  divides  the  pox  into  the  fol- 
lowing periods:  (i)  period  oi  primary  incubation — the  time 
between  exposure  and  the  appearance  of  the  chancre :  from 
ten  to  ninety  days,  the  average  being  three  weeks  ;  (2)  period 
of  primary  symptoms — chancre  and  bubo  of  adjacent  lymph- 
glands  ;  (3)  period  oi  secondary  incubation — the  time  between 
the  appearance  of  the  chancre  and  the  advent  of  secondary 
symptoms  :  about  six  weeks  as  a  rule ;  (4)  period  of  secon- 
dary symptoms — lasting  from  one  to  three  years ;  (5)  inter- 
mediate period — there  may  be  no  symptoms  or  may  be  light 
symptoms  vvhich  are  less  symmetrical  and  more  general  than 
those  of  the  secondary  period :  it  lasts  from  two  to  four 
years,  and  ends  in  recovery  or  tertiary  syphilis ;  and  (6) 
period  of  tertiary  symptoms — indefinite  in  duration. 

Primary  Syphilis. — The  primary  stage  comprises  the 
chancre  or  infecting  sore  and  bubo.  A  chancre  or  initial  lesion 
is  an  infective  granuloma  resulting  from  the  poison  of  syphilis. 
A  chancre  may  be  derived  from  the  discharges  of  another 
chancre,  from  the  secretion  of  mucous  patches  and  moist 
papules,  from  syphilitic  blood,  or  from  the  pus  or  secretion  of 
any  secondary  lesion.  Tertiary  lesions  cannot  cause  chancre. 
It  appears  at  the  point  of  inoculation,  and  is  the  first  lesion 


1 68  A   MANUAL    OF  SURGERY. 

of  the  disease.  It  is  not  a  local  lesion  from  which  syphilis 
springs,  but  is  a  local  manifestation  of  an  existing  constitu- 
tional disease,  hence  excision  is  entirely  useless.  If  we  take 
the  discharge  of  a  chancre  and  insert  it  at  some  indifferent 
point  into  the  person  from  whom  we  took  it,  a  new  chancre 
will  not  be  formed,  because  he  already  has  syphilis.  If  we 
insert  it  into  another  person,  a  chancre  is  formed.  Hence 
we  say  that  primary  syphilis  is  not  auto-inoculable,  but  is 
hetero-inoculable. 

Initial  Lesions. — An  initial  lesion,  hard  chancre,  or  infect- 
ing sore  never  appears  until  at  least  ten  days  after  exposure ; 
it  may  not  appear  for  many  weeks,  but  it  usually  arises  in 
about  three  weeks.  There  are  three  chief  forms  of  initial 
lesion:  (i)  a  purple  patch  exposed  by  peeling  epidermis, 
without  induration  and  ulceration — a  rare  form  ;  (2)  an  indu- 
rated area  under  the  epidermis,  without  ulceration — a  very 
common  form  ;  and  (3)  a  round,  indurated,  cartilaginous  area 
with  an  elevated  edge,  which  ulcerates,  exposing  a  velvety 
surface  looking  like  raw  ham  ;  it  bleeds  easily,  it  rarely  sup- 
purates, it  does  not  spread,  and  the  discharge  is  thin  and 
watery.  This  is  the  "  Hunterian  chancre,"  which  is  rarer 
than  the  second  variety,  but  commoner  than  the  first,  and 
which  ulcerates  because  of  dirt,  caustic  applications,  or  fric- 
tion. 

Mixed  Infection  of  Chancre  and  Chancroid. — A  chancre 
is  rarely  multiple,  but  if  it  is  so  all  the  sores  appear  together 
as  a  result  of  the  primary  inoculation :  they  do  not  follow 
one  another  because  of  auto-infection.  A  hard  sore  does 
not  suppurate  unless  irritated  by  caustics,  friction,  or  dirt,  or 
unless  there  be  mixed  infection  with  chancroid ;  its  nature  is 
not  to  suppurate.  The  hardness  may  affect  only  the  base 
and  margins  of  an  ulcer  or  it  may  affect  considerable  areas, 
but  it  has  well-defined  margins  and  feels  like  cartilage  encap- 
suled,  so  that  it  can  be  picked  up  in  the  fingers.     This  hard- 


SYPHILIS.  169 

ness  or  sclerosis  is  due  to  gradual  inflammatory  exudation 
into  '*  the  tissues  at  the  base  of  the  ulcer  and  to  growth  of 
the  nodule"  (Von  Zeissl).  A  chancre  untreated  may  last 
many  months.  The  induration  usually  disappears  soon  after 
the  appearance  of  secondary  symptoms.  A  copper-colored 
spot  remains,  and  does  not  disappear  until  the  disease  is 
cured.  An  induration  may  again  appear  before  the  outburst 
of  some  distant  lesion. 

Von  Zeissl  says  :  "  If  syphilitic  contagion  is  mixed  with 
pus,  a  chancre  begins  as  a  circumscribed  area  of  hyperaemia 
and  swelHng,  which  undergoes  ulceration,  and  does  not  de- 
velop hardness  for  a  period  of  from  ten  days  to  several  weeks, 
and  may  develop  a  nodule  after  the  first  ulcer  has  entirely 
healed."  We  see  this  condition  when  mixed  infection  occurs, 
the  chancroid  poison  being  quick,  and  the  syphilitic  poison 
being  slow,  to  act.  If  chancroid  poison  is  deposited  some 
time  after  the  syphilitic  poison  has  been  absorbed,  the  indu- 
ration may  appear  in  a  few  days  after  the  chancroid  begins. 
A  soft  chancre  may  appear  upon  an  existing  syphilitic  nodule 
and  may  eat  out  the  induration.  We  must  separate  a  chancre 
from  a  chancroid  and  from  ulcerated  herpes.  A  chancroid 
appears  in  from  two  to  five  days  after  contagion  (always  less 
than  ten  days) ;  it  may  be  multiple  from  the  start,  but,  even 
if  beginning  as  one  sore,  other  sores  appear  by  auto-inocu- 
lation ;  it  begins  as  a  pustule,  which  bursts  and  exposes  an 
ulcer ;  this  ulcer  is  circular,  has  thin,  sharp-cut  or  undermined 
edges,  a  sloughy,  non-granulating  base,  and  a  thin,  purulent, 
offensive  discharge  which  is  both  auto-  and  hetero-inoculable. 
These  soft  sores  have  no  true  sclerotic  area,  do  not  bleed, 
produce  no  constitutional  symptoms,  and  are  apt  to  be  fol- 
lowed by  an  acute  inflammatory  bubo  which  tends  to  suppu- 
rate. A  chancroid  causes  pain.  A  chancre  appears  in  about 
three  weeks  after  inoculation  (never  before  ten  days) ;  it  is 
generally  single,  but  if  multiple  sores  exist,  they  all  appear 


I/O  A    MANUAL    OF  SURGERY. 

together,  for  their  discharge  is  not  auto-inoculable  ;  it  begins 
as  an  excoriation  or  as  a  nodule ;  if  an  ulcer  forms,  its  base 
is  covered  with  granulations  and  it  is  red  and  smooth  ;  its 
discharge  is  thin  and  scanty  and  not  offensive ;  its  edges  are 
thick  and  sloping;  it  is  surrounded  by  an  area  of  induration, 
and  bleeds  when  touched  ;  it  is  followed  by  secondary  symp- 
toms, and  there  appear  about  the  same  time  with  it  indolent 
multiple  enlargements  of  the  adjacent  glands,  which  rarely 
suppurate.     A  chancre  causes  little  pain. 

Herpetic  ulceration  has  no  period  of  incubation ;  it  may 
follow  fever,  but  usually  arises  from  friction  or  the  irritation 
of  dirt  or  acrid  discharges.  It  appears  as  a  group  of  ves- 
icles, all  of  which  may  dry  up,  or  some  may  dry  up  and 
others  ulcerate,  or  they  may  run  together  and  ulcerate.  The 
edges  of  a  herpetic  ulcer  are  in  "  segments  of  small  circles  " 
(White) ;  the  ulcer  is  superficial,  has  but  little  discharge,  and 
does  not  have  much  tendency  to  spread ;  it  has  no  indura- 
tion ;  it  is  painful ;  it  has  no  bubo  unless  suppuration  is 
extensive,  and  there  is  no  constitutional  involvement.  A 
urethral  chancre  appears  after  the  usual  period  of  incubation  ; 
it  is  situated  near  the  meatus,  one  lip  of  which  is  usually 
indurated ;  the  discharge  is  slight,  often  bloody,  and  never 
purulent ;  indurated  multiple  buboes  arise ;  the  sore  can 
be  seen,  and  constitutional  symptoms  follow  (White).  "A 
chancre  may  be  mistaken  for  cancer  of  the  tongue.  A  chancre 
of  this  region  is  brownish-red,  a  cancer  being  bright  red. 
A  chancre  is  soft  in  the  centre ;  a  cancer  presents  uniformity 
of  induration.  A  chancre  has  a  thin,  purulent  discharge,  free 
from  blood ;  a  cancer  has  a  non-purulent,  bloody  discharge. 
A  chancre  is  followed  by  indolent  lymphatic  enlargements 
under  the  jaw ;  a  cancer  is  followed  by  painful  enlarge- 
ments." A  cancer  is  slower  in  evolution,  is  not  followed  by 
constitutional  symptoms,  and  the  lymphatic  enlargements 
are  much  later  in  appearing  than  in  chancre. 


SYPHILIS.  171 

Syphilitic  Bubo. — In  syphilitic  bubo  anatomically-related 
lymphatic  glands  enlarge  about  the  same  time  as  induration 
of  the  initial  lesion  begins.  In  the  very  beginning  these 
glands  may  be  a  little  painful,  but  they  soon  cease  to  be  so. 
These  enlargements  are  called  "indolent  buboes;"  they  may 
be  as  small  as  peas  or  as  large  as  walnuts,  are  freely  movable, 
and  very  rarely  suppurate.  The  lesion  of  these  glands  is 
hyperplasia  of  all  the  gland-elements  and  of  their  capsules, 
due  to  absorption  of  the  virus.  If  a  man  is  strumous,  the 
bubo  is  apt  to  become  enormous,  lobulated,  and  persistent. 
If  the  chancre  appears  on  the  penis,  the  superficial  inguinal 
and  femoral  glands  enlarge,  usually  on  the  same  side  of  the 
body  as  the  sore ;  if  the  sore  is  on  the  fraenum,  both  groins 
are  involved.  These  buboes  may  remain  for  many  months ; 
they  do  not  suppurate  unless  the  sore  suppurates  or  there  is 
some  condition  such  as  scrofula ;  and  they  finally  disappear 
by  absorption  or  fatty  degeneration.  About  six  weeks  after 
buboes  have  formed  in  the  glands  related  to  the  lesion,  all 
the  lymphatics  of  the  body  enlarge.  General  lymphatic 
involvement  arises  about  the  same  time  as  the  secondary 
eruption.  The  enlargement  of  the  post-cervical  and  epitroch- 
lear  glands  is  diagnostically  important.  These  glandular 
enlargements  persist  until  after  the  eruptions  have  disappeared. 

The  bubo  of  syphilis  is  always  present,  while  the  bubo 
exists  in  only  one-third  of  the  chancroid  cases.  The  bubo 
of  syphilis  is  multiple,  consisting  of  a  chain  of  movable 
glands  (the  glandulae  Pleiades  of  Ricord) ;  the  bubo  of  chan- 
croid is  one  inflamed  and  immovable  mass.  The  bubo  of 
syphilis  is  indurated,  painless,  small,  and  slow  in  growth  ; 
the  bubo  of  chancroid  shows  inflammatory  hardness,  is  pain- 
ful, large,  and  rapid  in  growth  ;  the  first  rarely  suppurates, 
the  second  often  does.  The  skin  over  a  syphilitic  bubo  is 
normal ;  that  over  a  chancroidal  bubo  is  red  and  adherent. 
A  syphilitic   bubo  is  not  cured  by  local   treatment,  but  is 


1/2  A    MANUAL    OF  SURGERY. 

cured  by  the  internal  use  of  mercury  and  is  followed  by 
secondary  symptoms.  A  chancroidal  bubo  requires  local 
treatment,  is  not  cured  by  mercury,  and  is  not  followed  by 
secondaries.  Herpes,  balanitis,  and  gonorrhoea  rarely  cause 
bubo,  but  when  they  do  the  bubo  in  each  case  is  similar  to 
that  caused  by  chancroid.  A  positive  diagnosis  of  syphilis 
can  be  made  when  an  indurated  sore  is  followed  by  multiple 
indolent  buboes  in  the  groin  and  by  enlargement  of  distant 
glands. 

General  Syphilis. — As  the  general  lymphatic  enlargement 
becomes  manifest  there  is  apt  to  appear  a  group  of  symp- 
toms known  as  "  syphilitic  fever."  The  patient  usually  thinks 
he  has  a  bad  cold  and  is  feverish  and  restless ;  he  complains 
of  sleeplessness  and  anorexia ;  his  face  is  pale ;  he  has  inter- 
mitting rheumatoid  pains  in  the  joints  and  muscles,  especially 
of  the  shoulders,  arms,  chest,  and  back,  which  pains  change 
their  location  constantly  and  prevent  sleep ;  night-sweats 
occur,  and  the  pulse  is  quite  frequent.  This  fever  usually 
reaches  its  height  in  forty-eight  hours,  and  falls  as  the  erup- 
tion develops.  Syphilitic  fever  does  not  always  arise ;  it 
may  appear  during  the  progress  of  the  disease. 

Secondary  Syphilis. — The  phenomena  of  secondary  syph- 
ilis arise  from  poisoned  blood.  They  are  characterized  by 
plastic  inflammation,  by  the  formation  of  fibrous  tissue,  and 
by  thickening  of  tissue.  Ulcerations  may  occur.  Structural 
overgrowths  appear  (warts). 

Syphilitic  Skin  Diseases. — Syphilodcriiiata  (syphilides), 
due  to  circumscribed  inflammation,  may  be  dry  or  purulent. 
There  is  no  one  eruption  characteristic  of  syphilis.  This  dis- 
ease may  counterfeit  any  skin  disease,  but  it  is  an  imitation 
which  is  not  perfect  and  is  never  a  counterpart.  Syphilitic 
eruptions  are  often  circumscribed;  they  terminate  suddenly  at 
their  edges,  and  do  not  gradually  shade  into  the  sound  skin. 
In  color  they  are  apt  to  be  brownish-red,  like  tarnished  cop- 


SYPHILIS.  173 

per  ;  especially  is  this  the  case  in  late  syphilides.  Hutchinson 
cautions  us  to  remember  that  an  ordinary  non-specific  erup- 
tion may  be  copper-colored,  especially  in  people  with  dark 
complexion  and  when  it  occurs  on  the  legs.  Eruptions  are 
apt  to  leave  a  brownish  stain.  Early  syphilitic  eruptions  are 
symmetrical.  Syphilitic  eruptions  have  an  affection  for  par- 
ticular regions,  such  as  the  forehead,  the  abdomen  and  chest, 
the  neck  and  scalp,  about  the  lips  and  the  alae  of  the  nose, 
the  navel,  anus,  groins,  between  the  toes,  and  upon  the  palms 
and  soles.  Early  secondary  eruptions  rarely  appear  on  the 
face  or  hands.  Specific  eruptions  are  polymorphous,  various 
forms  of  eruption  being  often  present  at  the  same  time, 
so  that  roseola  is  seen  here,  papules  there,  etc.  These 
syphilides  do  not  cause  as  much  itching  as  do  non-spe- 
cific eruptions,  except  when  about  the  anus  or  between 
the  toes. 

Forms  of  Eruption. — The  chief  forms  of  eruption  are 
(i)  erythema,  (2)  papular  syphilides,  (3)  pustular  syphilides, 
and  (4)  tubercular  syphilides. 

I.  Erythema  (inaciila,  roseola,  or  spots)  presents  round,  cir- 
cumscribed, red,  inflamed  spots  whose  color  does  not  entirely 
disappear  on  pressure.  In  the  papular  form  of  erythema  the 
spots  are  a  little  elevated.  It  attacks  especially  the  chest  and 
belly,  but  appears  often  on  the  forehead,  the  bend  of  the 
elbow,  and  the  inner  portion  of  the  thigh.  Usually  erythema 
follows  syphilitic  fever,  about  six  weeks  after  the  chancre 
appears,  and  the  number  and  distinctness  of  these  spots  are 
in  proportion  to  the  violence  of  the  fever.  Absent  or  slight 
fever  means  few  and  transient  spots.  In  rare  cases  the  dis- 
ease is  very  transitory,  lasting  but  a  few  hours,  but  it  usually 
lasts  for  a  long  period  if  untreated.  Mercury  will  cause  it  to 
disappear  in  a  couple  of  weeks.  In  examining  for  this  form 
of  eruption  in  a  doubtful  case,  let  cold  air  blow  upon  the 
chest  and  belly  (Hearn);  this  blanches  the  sound  skin  and 


174  A   MANUAL    OF  SURGERY. 

makes  clear  any  discoloration.     Erythema  means,  as  a  rule, 
a  mild  and  curable  attack. 

2.  Papular  sypJiilides,  which  are  papules  or  elevations  cov- 
ered with  dry  skin,  may  or  may  not  have  a  crust.  They  are 
at  first  red,  but  become  brownish.  Papules  upon  the  palms 
and  soles  constitute  the  so-called  "  palmar  and  plantar  psori- 
asis," which  appears  about  eight  or  nine  weeks  after  the 
appearance  of  the  chancre  in  an  untreated  case.  These 
papules  just  below  the  line  of  the  hair  on  the  forehead  con- 
stitute the  corona  vejierea.  This  eruption  affects  especially 
the  forehead,  the  neck,  the  abdomen,  and  the  extremities. 
The  papular  or  squamous  syphilide  of  the  palms  and  soles 
begins  as  a  red  spot  which  becomes  elevated  and  brownish ; 
the  epidermis  thickens  and  is  cast  off,  and  there  then  re- 
mains a  central  red  spot  surrounded  by  undermined  skin. 
If  papules  are  in  regions  where  they  are  kept  moist  (as 
about  the  anus),  they  become  covered  with  a  sodden  gray 
film  which  comes  off  and  leaves  the  papule  without  epidermis. 
These  sodden  papules  are  called  "  flat  condylomata,"  moist 
or  humid  papules  or  plates.  The  papular  syphilide  gives  a 
worse  prognosis  than  roseola. 

3.  Pustular  syphilides  arise  from  papules.  We  have  acne 
when  the  apex  of  a  papule  softens,  impetigo  when  the  whole 
papule  suppurates,  and  ecthyma  or  rupia  when  the  corium  is 
also  deeply  involved.  Vesicles  often  precede  pustules,  the 
pustular  eruption  coming  out  some  months  after  infection 
(later  than  the  papular).  The  pustular  eruption  gives  a  very 
bad  prognosis.  Rupia  is  formed  by  a  pustule  rupturing  or 
a  papule  ulcerating,  the  secretion  drying  and  forming  a  con- 
ical crust  which  continually  increases  in  height  and  diameter, 
while  the  ulceration  extends  at  the  edges.  When  the  crust 
is  pulled  off  there  is  seen  a  foul  ulcer  with  congested,  jagged, 
and  undermined  edges.  Rupia  may  be  secondary  or  tertiary, 
and  it  invariably  leaves  scars.     It  appears  only  after  at  least 


SYPHILIS.  175 

six  months  have  passed  since  the  chancre  began.  Secondary 
rupia  is  symmetrical. 

4.  Tubercular  sypJiilides  are  greatly  enlarged  papules  inter- 
mediate between  ordinary  papules  and  gummata. 

Diagnosis  bctzveen  Secondary  and  Tertiary  Syphilides, — A 
secondary  eruption  is  distinguished  from  a  tertiary  eruption 
by  the  following :  the  first  tends  to  disappear,  the  second  tends 
to  persist  and  to  spread ;  the  first  is  symmetrical,  the  second 
is  asymmetrical ;  the  first  does  not  spread  at  its  edge,  the 
second  tends  to  spread  at  its  edge,  and  this  tendency,  which 
is  designated  "  serpiginous,"  produces  an  ulcer  shaped  like 
a  horse-shoe  (Jonathan  Hutchinson). 

Affections  of  the  Mucous  Membranes. — The  chief  lesions 
in  syphilitic  affections  of  the  mucous  membranes  are  mucous 
patches,  warts,  and  condylomata.  The  first  phenomena  of 
secondary  syphilis  are,  as  a  rule,  symmetrical  ulcers  of  the 
tonsils,  painless  and  superficial  (Hutchinson).  The  borders 
of  the  ulcers  are  gray,  and  the  areas  are  reniform  in  shape. 
They  rarely  last  long.  Catarrhal  inflammations  often  occur. 
Eruptions  appear  on  the  mucous  membranes  or  upon  the 
skin.  Mucous  patches  are  papules  deprived  of  epithelium ; 
they  are  gray  in  color,  are  moist,  and  giv^e  off  an  offensive 
and  virulent  discharge.  They  usually  appear  as  areas  of 
congestion,  swelling,  and  abrasion  of  the  epidermis  upon 
the  lips,  palate,  gums,  tongue,  cheeks,  vagina,  labiae,  vulva, 
scrotum,  anus,  and  under  the  prepuce.  A  moist  papule  of 
the  skin  is  really  a  mucous  patch.  These  patches,  which  are 
always  circular  or  oval,  are  among  the  most  constant  lesions 
of  the  secondary  stage,  appearing  from  time  to  time  during 
many  months.  If  a  patch  has  the  papillae  destroyed,  it  is 
called  a  "bald  patch."  If  the  papules  present  hypertrophied 
papillae  fused  together,  there  appear  enlargements  with  flat 
tops  termed  "condylomata;"  if  the  papillae  of  the  papule 
hypertrophy  and  do  not  fuse,  the  growths  are  called  "  warts." 


176  A   MANUAL    OF  SURGERY. 

Mucous  lesions  of  the  mouth  are  commonest  in  smokers 
and  in  those  with  bad  or  neglected  teeth.  Hutchinson  says 
that  persistence  in  smoking  during  syphilis  may  cause  leuco- 
mata,  or  persistent  white  patches.  The  larynx  may  suffer 
from  inflammation,  eruptions,  and  ulceration  (hence  the 
hoarse  voice  which  is  so  usual).  The  nasal  mucous  mem- 
brane may  also  suffer. 

Affections  of  the  Hair. — In  syphilitic  affections  the  hair 
is  shed  to  a  great  extent.  This  loss  may  be  widespread 
(beard,  mustache,  head,  eyebrows,  pubic  hair,  etc.)  or  it  may 
be  limited.  Complete  baldness  sometimes  ensues,  but  this 
is  rarely  permanent.  The  hairs  are  first  noticed  to  come  out 
on  the  comb ;  on  pulling  them  they  are  found  loose  in  their 
sheaths — so  loose  that  Ricord  has  said  ''  a  man  would  drown 
if  a  rescuer  could  pull  only  upon  the  hair  of  the  head." 
This  falling  out  of  the  hair,  which  is  known  as  "alopecia," 
begins  soon  after  the  fever  or  about  the  time  of  the  eruption, 
but  it  may  be  postponed.  The  skin  of  a  syphilitic  bald  spot 
is  never  smooth,  but  is  scaly.  The  hair  may  thin  generally, 
baldness  may  appear  in  twisting  lines,  or  it  may  be  complete 
only  in  limited  areas.  Alopecia  results  from  shrinking  of  the 
hair-pulp,  death  of  the  hair,  and  casting  off  of  the  sheath. 

Affections  of  the  Nails. — Paronychia  is  inflammation  and 
ulceration  of  the  skin  in  contact  with  a  nail  and  extending 
to  the  matrix.  The  nail  is  cast  off  partially  or  entirely. 
Onychia  is  manifested  by  white  spots,  brittleness  or  extended 
opacity,  twisting,  and  breaking  off  of  the  nail.  The  parts 
around  are  not  affected.  The  damaged  nail  drops  off  and 
another  diseased  nail  appears. 

Affections  of  the  Ear. — Temporary  impairment  of  hearing 
in  one  or  both  ears  is  not  uncommon  in  syphilitic  affections 
of  the  ear.  Rarely,  permanent  symmetrical  deafness  is  pro- 
duced.    Meniere's  disease  is  sometimes  caused  by  syphilis. 

Affections  of  the  Bones  and  Joints. — In  syphilis  there 


SYPHILIS.  177 

may  be  slight  and  temporary  periostitis.  Pain  and  tender- 
ness arise  in  various  bones,  the  pain  being  worse  at  night 
(osteoscopic  pains).  The  bones  usually  involved  are  the 
tibiae,  clavicles,  and  skull.  Pain  like  that  of  rheumatism 
affects  the  joints.  Local  periostitis  may  form  a  soft  node 
which  by  ossification  becomes  a  hard  node. 

Affections  of  the  Bye. — Iritis  is  the  commonest  trouble 
of  the  eyes.  It  appears  from  three  to  six  months  after  the 
chancre,  and  begins  in  one  eye,  the  other  eye  soon  becoming 
affected.  The  symptoms  are  a  pink  zone  in  the  sclerotic, 
ciliary  congestion,  muddy  iris,  irregular  pupil  accentuated 
by  atropine,  pain  and  photophobia,  and  sometimes  hazy  or 
even  blocked  pupil.  Rheumatic  iritis  causes  much  pain  and 
photophobia,  syphilitic  iritis  comparatively  little ;  there  is  less 
swelling  in  the  first  than  in  the  second ;  the  former  tends  to 
recur,  the  latter  does  not.  Iritis  is  usually  recovered  from, 
good  vision  being  retained.  Diffuse  retinitis  and  disseminated 
choroiditis  never  occur  until  a  number  of  months  have  passed 
since  the  infection.  The  symptoms  are  failure  of  sight,  mus- 
cae  volitantes,  and  very  little  photophobia.  Diagnosis  of 
retinitis  and  choroiditis  is  by  the  ophthalmoscope. 

Affections  of  the  Testes. — Syphilitic  Sarcoccle. — The 
testes  enlarge  from  plastic  inflammation.  Both  glands  usu- 
ally suffer,  but  not  always.  Fluid  distends  the  tunica  vagi- 
nalis. The  epididymis  escapes.  The  testicle  is  not  the 
seat  of  pain,  is  troublesome  because  of  its  weight,  and  has 
very  little  of  the  proper  sensation  on  squeezing.  The  plastic 
exudate  is  generally  largely  absorbed,  but  it  may  organize 
into  fibrous  tissue,  the  organ  passing  into  atrophic  cirrhosis. 

Intermediate  Period. — In  this  period  no  symptoms  may 
appear,  but  the  disease  is  still  for  some  time  latent  and  is  not 
cured.  Symptoms  may  appear  from  time  to  time.  These 
symptoms,  which  are  called  "  reminders,"  are  not  so  severe  as 
tertiary  symptoms  ;  reminders  are  apt  to  be  symmetrical,  and 
12 


178  A   MANUAL    OF  SURGERY. 

they  do  not  closely  resemble  secondary  lesions.  Among  the 
reminders  we  may  name  palmar  psoriasis,  sarcocele,  sores  on 
the  tongue,  a  papular  skin-eruption,  and  choroiditis.  Gum- 
mata  occur  in  this  stage,  but  they  are  apt  to  be  symmetrical 
and  non-persistent.  Arteritis  occurs,  beginning  in  the  intima 
or  adventitia,  and  causing,  it  may  be,  aneurysm,  embolism,  or 
thrombosis.  Obliterative  endarteritis  may  cause  gangrene. 
This  vascular  condition  is  frequent  in  the  brain ;  thrombosis 
may  occur,  in  which  case  a  paralysis  comes  on  gradually, 
preceded  by  numbness,  although  sudden  paralysis  may  occur. 
These  paralyses  may  be  limited,  extensive,  transitory,  or  per- 
manent. The  nervous  system  often  suffers  in  this  stage 
(anaesthetic  areas  and  retinitis).  The  viscera  are  often  con- 
gested and  infiltrated  (tonsils,  liver,  spleen,  kidneys,  and 
lungs). 

Tertiary  Syphilis. — This  stage  is  not  often  reached,  the 
disease  being  cured  before  it  has  been  attained.  It  is  re- 
garded by  many  as  not  so  much  a  stage  of  syphilis  as  a 
condition  of  impaired  nutrition  which  results  from  the  dis- 
ease. This  view  finds  confirmation  in  the  fact  that  tertiary 
lesions  do  not  furnish  the  contagion.  The  primary  stage 
disappears  without  treatment,  the  secondary  stage  tends  ulti- 
•timately  to  spontaneous  disappearance,  but  tertiary  lesions 
tend  to  persist  and  to  recur.  Tertiary  lesions  may  be  single 
or  may  be  widely  scattered  ;  when  multiple  they  are  not 
symmetrical  except  by  accident.  These  lesions  may  attack 
any  tissue,  even  after  many  years  of  apparent  cure ;  they  all 
tend  to  spread  locally,  they  all  leave  permanent  atrophy  or 
thickening,  they  all  tend  to  relapse,  and  a  local  influence  is 
often  an  exciting  cause. 

Tertiary  skin-eriiptions  are  liable  to  ulcerate.  The  charac- 
teristic syphilide  is  riipia,  which  is  formed  by  a  pustule  rup- 
turing or  a  papule  ulcerating.  A  scab  forms  because  of  the 
drying  of  the  discharge,  ulceration  continues  under  the  scab, 


SYPHILIS.  179 

new  scabs  form,  and,  as  the  ulcer  is  constantly  increasing 
peripherally,  the  new  scabs  are  larger  in  diameter  than  the 
old  ones,  and  the  crust  assumes  the  form  of  a  cone.  An 
ulcer  is  exposed  by  tearing  off  the  scab,  which  ulcer  has 
destroyed  the  deeper  layers  of  the  skin,  and  on  healing 
always  leaves  a  permanent  scar. 

Ulcers  are  common  in  tertiary  syphilis.  They  are  frequent 
on  the  legs,  especially  about  the  knees.  A  syphilitic  ulcer 
is  usually  crescentic,  its  edges  are  thin  and  sharp,  its  base 
is  foul  and  sloughy,  and  its  discharge  is  scanty  and  tenacious. 

Guvima. — The  gumma  is  the  t3'pical  tertiary  lesion.  A 
gumma  arises  from  an  inflammation  the  products  of  which 
cannot  organize  for  want  of  sufficient  blood-supply,  and 
consequently  they  undergo  fatty  degeneration.  A  gumma 
presents  a  centre  of  gummy  degeneration,  a  surrounding  area 
of  immature  fibrous  tissue,  and  an  outer  zone  of  embr)^onic 
tissue  and  leucoc)'tes.  A  gumma,  when  it  is  spontaneously 
evacuated,  exhibits  a  small  opening  with  very  thin  under- 
mined edges  ;  the  ulcer  is  slow  to  heal,  and  forms  a  depressed 
scar.  A  gumma  in  the  internal  organs  may  become  a  fibrous 
mass.  These  gummata  form  in  the  skin,  subcutaneous  tissues, 
muscles,  tongue,  joints,  bursae,  testes,  spinal  cord,  brain,  and 
internal  organs.  In  tertiary  syphilis  an  inflammation  may 
not  form  a  circumscribed  gumma,  but,  instead,  may  produce 
a  diffuse  degenerating  mass.  This  type  of  inflammation, 
which  is  seen  in  bones,  is  called  "  gummatous."  A  healing 
gumma  in  a  mucous  canal  such  as  the  rectum  or  larynx 
causes  thickening  and  stricture.  Tertiary  syphilis  is  a  most 
common  cause  of  amyloid  degenerations  and  arterial  and 
nervous  sclerosis. 

Various  Zf.w;/.s-.— Hutchinson  enumerates  the  lesions  of 
tertiary  syphilis  as  follows :  Periostitis,  forming  nodes  or 
causing  sclerotic  hypertrophy  or  suppuration  or  necrosis ; 
gummata  in  various  parts ;  disease  of  the  skin  of  the  type 


l8o  A   MANUAL    OF  SURGERY. 

of  rupia  or  lupus ;  gumma  or  inflammation  of  tongue,  causing 
sclerosis ;  structural  changes  in  the  nervous  system,  causing 
ataxia,  ophthalmoplegia  externa  and  interna,  general  paresis, 
optic  atrophy,  and  paralyses  of  cerebral  nerves ;  amyloid 
degenerations;  and  chronic  inflammation  of  certain  mucous 
membranes  (of  the  mouth,  pharynx,  vagina,  rectum,  etc.), 
with  thickening  and  ulceration. 

Visceral  Syphilis. — In  visceral  syphilis  the  lungs  may 
undergo  fibroid  induration  (syphilitic  phthisis).  Syphilitic 
phthisis  is  a  non-febrile  malady.  Gummata  may  form  in  the 
heart,  liver,  spleen,  or  kidneys  ;  the  capsule  and  fibrous  septa 
of  the  liver  may  thicken,  the  organ  being  puckered  from  con- 
traction.   Amyloid  changes  may  appear  in  any  of  the  viscera. 

Nef"Vous  syphilis  may  be  manifest  in  disorders  of  the 
brain,  cord,  or  nerves.  Much  of  our  knowledge  of  these 
conditions  is  due  to  Wood.  He  says  brain  syphilis  is  usu- 
ally a  late  phenomena  (from  one  to  thirty  years),  and  is  more 
apt  to  appear  after  light  secondaries.  The  lesion  may  be 
gumma  of  the  membranes  (tumor),  gummatous  meningitis, 
arterial  atheroma,  or  obliterative  endarteritis.  A  gumma  may 
eventuate  in  a  scar,  a  cyst,  or  a  calcareous  mass.  The  symp- 
toms of  brain  syphilis  depend  on  the  nature,  seat,  and  rate 
of  development  of  the  lesions.  It  is  to  be  noted  that 
syphilitic  palsy  is  apt  to  be  limited,  progressive,  and  incom- 
plete. Epilepsy  appearing  after  the  thirtieth  year  is  very 
probably  specific  if  alcohol  can  be  ruled  out.  Persistent 
headache,  insomnia  or  somnolence,  transitory  limited  pal- 
sies, unnatural  slowness  of  utterance,  amnesia,  vertigo,  and 
epilepsy  are  very  suggestive.  The  more  usual  type  of  in- 
sanity is  a  likeness  or  counterpart  of  general  paralysis. 
Spinal  syphilis  may  cause  sclerosis,  a  condition  like  Landry's 
paralysis,  softening,  and  tumor.  Neuritis  is  not  uncommon 
in   syphilis. 

Treatment  of  Primary  Stage. — A  chancre  should  not  be 


SYPHILIS.  l8l 

excised.  The  disease  is  constitutional  when  the  chancre 
appears,  and  excision  and  cauterization  inflict  needless  pain 
and  do  no  good.  The  initial  lesion  should  never  be  burned 
unless  it  is  phagedaenic  or  becoming  so.  Order  the  patient 
to  soak  the  penis  for  five  minutes  twice  daily  in  warm  salt 
water  (a  teaspoonful  of  salt  to  a  cupful  of  water),  and  then 
to  spray  the  sore  by  an  atomizer  with  peroxide  of  hydrogen 
(14-volume  solution  of  peroxide  diluted  with  an  equal  bulk 
of  water). .  The  ulcer  is  then  dried  with  absorbent  cotton 
and  on  it  is  dusted  a  powder  of  equal  parts  of  bismuth 
and  calomel.  The  buboes  in  the  groin  require  no  local 
treatment  unless  they  tend  to  suppurate.  If  they  persist 
or  become  large,  paint  them  with  iodine,  smear  blue  oint- 
ment over  them,  and  apply  a  spica  bandage  of  the  groin. 
Ichthyol  and  lanolin  make  an  excellent  application  for  the 
enlarged  glands,  and  so  does  mercurial  ointment.  Some 
authorities  give  mercury  in  this  stage,  claiming  that  it  pre- 
vents secondaries.  The  late  S.  W.  Gross  opposed  this 
strongly,  and  affirmed  a  wish  to  see  the  secondary  erup- 
tion— first,  because  it  proves  the  diagnosis ;  and  second, 
because  it  affords  valuable  prognostic  indications  (an  ery- 
thematous eruption  means  a  light  case  ;  an  early  pustular 
eruption  means  a  grave  case  with  serious  complications). 
Dr.  White  will  not  order  mercury  until  constitutional  symp- 
toms develop. 

Treatment  of  Secondary  Stag-e. — In  the  secondary  stage 
the  aim  is  to  cure  the  disease.  That  it  can  be  cured  is  known 
from  the  fact  that  reinfection  occurs  in  some  persons.  The 
old  axiom,  "  Syphilis  once,  syphilis  ever,"  is  not  true.  Mer- 
cury m'ust  be  used,  the  form  being  a  matter  of  choice. 
Fournier  finst  advocated  intermittent  treatment.  In  this  plan 
give  gr.  \  of  protiodide  of  mercury  daily  for  six  months, 
then  stop  a  month  ;  then  give  mercury  for  three  months, 
then  stop  two  months.     During  the  first  year  the  patient  is 


1 82  A   MANUAL    OF  SURGERY. 

under  treatment  nine  months,  and  during  the  second  year 
eight  months.  Some  prefer  the  intermittent  and  others  the 
continuous  plan  of  treatment.  Dr.  White  greatly  prefers  the 
continuous  plan.  The  rule  in  most  cases  is  to  give  mer- 
cury for  two  years.  Find  the  patient's  dose  of  tolerance, 
and  keep  him  on  this  amount.  Gross's  rule  for  continuous 
treatment  was  to  order  pills  of  the  green  iodide  of  mer- 
cury, each  pill  containing  gr.  \.  The  patient  was  ordered 
one  pill  after  each  meal  to  begin  with  ;  the  next  day  he  took 
two  pills  after  breakfast ;  the  following  day,  two  after  din- 
ner, and  so  on,  adding  one  pill  every  day.  This  advance 
was  continued  until  there  was  slight  diarrhoea,  griping,  a 
metallic  taste,  or  tenderness  on  snapping  the  teeth  together, 
whereupon  one  pill  was  taken  off  each  day  until  all  unfavor- 
able symptoms  disappeared.  This  experimentation  gives  a 
dose  on  which  the  patient  can  be  kept  with  entire  safety  for 
a  long  time,  but  if  it  is  found  that  colic  or  diarrhoea  is  apt 
to  recur,  there  must  be  added  to  each  pill  gr.  -^  of  opium. 
The  patient  is  given  mercury  in  this  way  for  two  years. 
Every  time  new  symptoms  appear  the  dose  is  raised,  and  as 
soon  as  they  disappear  it  is  lowered  to  the  standard.  If  the 
protiodide  is  not  tolerated,  give  the  bichloride : 

R.  Hydrarg.  clilor.  corros.,  gr.  iss; 

Syr.  sarsaparillae  comp.,  fl^v. — M. 

Sig.  fjj  in  water  after  meals. 

Mercury  with  chalk  in  i -grain  doses  four  times  a  day,  with 
or  without  Dover's  powder  in  ^^-grain  doses,  can  be  used. 
Mercurial  inunctions  produce  a  rapid  effect,  but  irritate  the 
skin.  There  can  be  used  once  a  day  ]4  drachm  of  oleate 
of  mercury  (lo  per  cent.)  or  i  drachm  of  mercurial  ointment, 
rubbed  in  one  day  on  the  inside  of  one  thigh  and  the  next 
day  on  the  inside  of  the  other  thigh  ;  next,  the  inside  of  one 
arm  and  then  the  other  arm ;  next,  one  groin  and  then  the 


SYPHILIS.  183 

other  groin,  and  so  on.  After  the  rubbing  the  patient  puts 
on  underclothes  and  goes  to  bed,  and  in  the  morning  takes 
a  bath.  The  ointment  may  be  smeared  on  a  rag,  which  is 
then  worn  between  the  stockingr  and  sole  of  the  foot  durine 
the  day. 

Fumigation  is  performed  by  volatilizing  each  night  3j  of 
calomel.  The  patient  sits  naked  on  a  cane-seat  chair,  the 
calomel  is  heated  by  an  alcohol  lamp  beneath  the  chair,  and 
wrapped  around  the  patient  is  a  blanket  which  drops  tent- 
like to  the  floor.  The  skin  becomes  coated  with  calomel, 
and  the  subject,  after  putting  on  woollen  drawers  and  an 
undershirt,  gets  into  bed.  Hypodermatic  injections  of  mer- 
cury are  used  by  some  physicians.  They  cause  an  eruption 
to  disappear  rapidly,  but  may  produce  abscesses,  and  relapses 
are  prone  to  occur.  The  usual  plan  is  to  give  daily  a  hypo- 
dermatic injection  of  corrosive  sublimate  deep  into  the  back 
or  buttocks,  the  dose  being  gr.  \  of  the  drug.  Thirty  such 
injections  are  used  unless  some  indication  points  to  their  dis- 
continuance sooner.  The  treatment  is  then  stopped.  If  the 
symptoms  recur,  however,  the  patient  is  given  another 
course,  the.  daily  dosage  being  gr.  |-,  the  treatment  being 
again  stopped  after  thirty  injections,  but  continued  anew  in 
^-grain  doses  if  the  symptoms  recur.  Dr.  Orville  Horwitz 
has  recently  made  thorough  trial  of  this  method,  and  arrives 
at  the  following  conclusions :  It  will  not  abort  the  disease  ; 
it  should  never  be  a  routine  treatment ;  in  suitable  cases  it  is 
very  valuable  for  symptomatic  use,  as  when  lesions  on  the 
face  or  in  important  structures  make  a  rapid  impression  de- 
sirable or  necessary  ;  in  cases  which  obstinately  relapse  under 
other  treatment,  and  in  syphilis  of  the  nervous  system. 

Dr.  J.  William  White,  who  has  the  right  to  speak  authori- 
tatively, says  that  hypodermatic  injections  of  corrosive  sub- 
limate are  painful  and  are  strongly  objected  to  by  many 
patients ;  that  this  method  of  treatment  is  occasionally  danger- 


184  A    MANUAL    OF  SURGERY. 

ous  and  even  fatal ;  tliat  it  is  liable  to  be  followed  by  local 
complications  (erythema,  nodosities,  cellulitis,  abscess, slough- 
ing) ;  that  it  cannot  be  carried  out  by  the  patient,  but  requires 
the  surgeon's  constant  intervention.  This  distinguished  syph- 
ilographer  concludes  that  hypodermatic  medication  does  not 
offer  advantages  justifying  its  use  as  a  systematic  method 
of  treatment,  and  that  it  encourages  insufficient  treatment — 
those  "  short  heroic  courses  "  which  Hutchinson  shows  are 
followed  by  the  gravest  tertiary  lesions.  "  The  claim  that 
by  a  few  injections  the  time  of  treatment  can  be  measured  by 
months  or  even  by  weeks,  instead  of  by  years,  would  seem, 
as  Mauriac  has  said,  to  involve  the  idea  that  mercury  given 
hypodermatically  acquires  some  new  and  powerful  curative 
property  which,  given  in  other  ways,  it  does  not  possess."^ 
In  whatever  way  mercury  is  given,  do  not  let  it  salivate 
(hydrargyrism). 

Acute  Ptyalism,  or  Salivation. — In  acute  ptyalism  the 
saliva  becomes  thick  and  excessive  in  amount ;  the  gums 
become  tender  (found  first  by  snapping  the  teeth),  spongy, 
and  tend  to  bleed  ;  a  metallic  taste  is  complained  of;  the 
breath  becomes  fetid ;  all  the  oral  structures  swell ;  the  teeth 
loosen  ;  the  saliva  is  enormously  increased  ;  and  there  are 
purging,  colic,  and  exhaustion.  A  chronic  hydrargyrism 
may  be  shown  by  gastro-intestinal  disorder,  emaciation, 
mental  depression,  weakness,  albuminuria,  and  tremor.  To 
avoid  salivation  cautiously  advance  the  dose  and  instruct 
the  patient  as  to  the  first  signs.  He  should  use  a  soft  tooth- 
brush and  an  astringent  mouth-wash  (gr.  xlviij  of  boracic 
acid  to  oiv  each  of  listerine  and  water).  When  ptyalism 
begins,  stop  the  drug.  Employ  the  above  mouth-wash  or 
one  composed  of  a  saturated  solution  of  chlorate  of  potas- 
sium.    Order  gr.  Y2Tr  ^^  atropine  twice  a  day,  and  in  bad 

^  Prof.  J.  William  \Yhite,  in  Morrow's  System  of  Genito-urinary  Diseases^ 
Syphilis,  and  Dermatology. 


SYPHILIS.  185 

cases  spray  the  mouth  with  peroxide  of  hydrogen  and  use 
silver  nitrate  locally  (gr.  xx  to  5J).  A  weekly  Turkish  bath 
is  of  great  use.  In  chronic  hydrargyrism  stop  the  drug,  use 
tonics,  stimulants,  open-air  exercise,  Turkish  baths,  and  good 
food.  The  chloride  of  gold  and  sodium  forms  a  good  sub- 
stitute drug. 

Treatment  of  Complications  in  Secondary  Stage. — The  com- 
plications of  the  secondary  stage  usually  require  local  appli- 
cations in  addition  to  general  remedies.  Mucous  patches  in 
the  mouth  should  be  touched  with  bluestone  every  day,  an 
astringent  mouth-wash  being  employed  several  times  daily. 
If  the  patches  ulcerate,  they  should  be  touched  twice  a 
day  with  lunar  caustic  ;  if  these  areas  proliferate,  they  should 
be  excised  and  burned.  Vegetations  or  growing  papules  on 
the  skin  must,  if  calomel  powder  fails  to  remove  them,  be 
cut  away  with  scissors  and  be  cauterized  with  chromic  acid 
or  with  the  Pacquelin  cautery.  Condylomata  demand  wash- 
ing with  ethereal  soap  several  times  daily,  thorough  drying, 
dusting  with  equal  parts  of  calomel  and  subnitrate  of  bis- 
muth or  with  borated  talcum,  and  covering  with  dry  bichlo- 
ride gauze.  If  these  simple  procedures  fail,  then  excise 
and  cauterize. 

For  psoriasis  of  the  palms  and  soles  diachylon  ointment, 
mercurial  plaster,  or  painting  with  tincture  of  iodine  should 
be  employed.  Ulcers  of  paronychia  are  dressed  with  iodo- 
form and  corrosive-sublimate  gauze.  Deep  cutaneous  ulcers 
are  cleaned  once  a  day  w^th  Johnson's  ethereal  soap,  then 
sprayed  with  peroxide  of  hydrogen,  dressed  with  iodoform 
and  corrosive-sublimate  gauze,  and  bandaged.  When  granu- 
lation is  w^ell  established  dress  with  i  part  of  unguent, 
hydrarg.  nitratis  to  7  parts  of  cosmoline.  In  sarcocele 
mercurial  ointment  should  be  used  or  the  testicle  be 
strapped.  Alopecia  requires  that  the  hair  be  kept  short 
and  every  night  the  scalp  be  cleaned  with  equal  parts  of 


1 86  A   MANUAL    OF  SURGE J^Y. 

green  soap  and  alcohol  rubbed  into  a  lather  with  water. 
After  the  soap  is  washed  out  some  hair  tonic  should  be 
rubbed  into  the  scalp  with  a  sponge. 

In  treating  persistent  skin-lesions,  inunctions,  injections, 
or  fumigations  may  be  used ;  some  prefer  mercurial  baths. 
Baths  are  suited  to  patients  with  delicate  skins,  to  those 
whose  digestion  fails  from  mercury  by  the  stomach,  and  to 
those  whose  lungs  will  not  tolerate  fumigations.  Half  an 
ounce  of  corrosive  sublimate  with  4  scruples  of  sal  ammoniac 
are  mixed  in  about  4  ounces  of  water;  this  is  added  to  a 
bath  at  a  temperature  of  95°.  The  patient  gets  into  this 
bath,  covers  the  tub  with  a  blanket,  leaving  only  his  head 
exposed,  and  remains  in  the  bath  an  hour  or  so.  These 
baths  may  easily  cause  salivation. 

In  every  case  of  syphilis,  no  matter  what  constitutional  or 
local  treatment  is  used,  the  general  health  of  the  patient  must 
be  watched  and  the  use  of  tobacco  be  stopped,  as  the  latter 
renders  certain  the  arrival  of  mucous  patches  and  causes 
them  to  persist.  Alcohol  as  a  beverage  must  be  cut  off: 
its  use  must  only  be  as  a  medicine  for  debility  and  weakness 
of  assimilation.  An  open-air  life  to  a  great  degree  must  be 
insisted  upon,  and  care  be  observed  as  to  protection  from 
damp  and  cold.  Order  flannels  in  winter.  Have  the  patient 
sponge  the  chest  and  shoulders  every  morning  with  cold  or 
with  tepid  water  and  then  with  alcohol,  drying  himself  with  a 
rough  towel,  and  take  a  hot  bath  twice  a  week  or  a  Turkish 
bath  once  a  week.  He  should  wash  the  anus  and  nates  after 
every  stool,  and  ought  to  dust  the  axillae,  scrotum,  perineum, 
and  internatal  region  once  a  day  with  borated  talc.  The 
teeth  are  to  be  looked  to  and  put  in  perfect  order,  a  soft 
brush  being  used  twice  a  day  and  an  astringent  mouth-wash 
being  frequently  employed.  Meat  and  milk  are  largely  to 
be  used.  The  patient  should  be  weighed  weekly :  any  fall- 
ing off  in  weight  is  an  indication  for  tonics,  concentrated 


SYPHILIS.  187 

food,  and  cod-liver  oil.  If  a  patient's  health  continues  to 
fail  on  mercury,  the  drug  should  be  stopped  for  some  time 
and  the  patient  be  treated  with  iron,  chloride  of  gold  and 
sodium,  baths,  fresh  air,  cod-liver  oil,  and  nourishing  foods. 
Reminders  require  mixed  treatment. 

Tertiary  Stage. — If  at  any  time  during  the  case  there 
appear  tertiary  symptoms,  the  patient  should  be  put  on 
mixed  treatment.  In  any  case,  after  two  years  of  mercury 
add  iodide. of  potassium  to  the  treatment.  Dr.  White's  rule 
is  to  use  this  mixed  treatment  for  at  least  six  months  (if  any 
symptoms  appear),  the  six-months  course  dating  from  their 
disappearance.  This  emphasizes  the  fact  that  the  iodides 
alone  will  not  cure  tertiary  syphilis.  In  obstinate  tertiaries 
or  in  nervous  syphilis  the  iodides  should  be  run  up  to  an 
enormous  amount  (from  30  to  250  grains  per  day).  An  easy 
way  to  give  iodide  is  to  order  a  saturated  solution  each  drop 
of  which  equals  one  grain  of  the  drug.  Each  dose  of  the 
iodide  is  given  one  hour  after  meals  and  in  at  least  half  a 
glass  of  water.  If  the  iodide  disagrees,  it  may  be  given  in 
water  containing  one  drachm  of  aromatic  spirits  of  ammonia 
or  in  milk.  The  iodide  of  sodium  may  be  tolerated  better 
than  the  potassium  salt,  or  the  iodides  of  sodium,  potassium, 
and  ammonium  mav  be  combined.  In  sj-iving^  the  iodides 
begin  with  a  small  dose.  During  a  course  of  the  iodide 
always  give  tonics  and  insist  on  plenty  of  fresh  ajr.  Arsenic 
tends  to  prevent  skin-eruptions.  The  iodides  when  they 
disagree  produce  iodism — a  condition  which  is  first  made 
manifest  by  running  of  the  nose  and  the  eyes.  In  some 
subjects  there  is  an  outbreak  of  acne,  vesicular  eruptions  or 
even  bullae,  or  hemorrhages.  Iodism  calls  for  a  reduction  in 
dosage,  and,  if  severe  or  persistent,  for  the  abandonment  of 
the  drug.  After  the  patient  has  been  for  six  months  under 
mixed  treatment  without  a  symptom,  stop  all  treatment  and 
await  developments.    If  during  one  year  no  symptoms  recur, 


1 88  A   MANUAL    OF  SURGERY. 

the  patient  is  probably  cured ;  if  symptoms  do  recur,  there 
must  be  six  months  more  of  treatment  and  another  year 
of  watch  ini^. 

Hereditary  Syphilis. —  Transmitted  co}igc)iital  sypldlis  is  a 
hereditary  syphilis  manifest  at  birth.  Acquired  syphilis 
(except  in  the  case  of  a  woman  who  obtains  the  disease  from 
a  foetus)  always  presents  the  chancre  as  an  initial  lesion ; 
hereditary  syphilis  never  does.  Hereditary  syphilis  may 
present  itself  at  birth,  and  usually  shows  itself  within,  at 
most,  the  first  six  months  of  extra-uterine  life.  In  rare 
cases  (tardy  hereditary  syphilis)  the  disease  does  not  become 
manifest  until  puberty. 

Rides  of  Inheritance. — According  to  Von  Zeissl,^  the  rules 
of  inheritance  are  as  follows  : 

1.  If  one  parent  is  syphilitic  at  the  time  of  procreation, 
the  child  may  be  .syphilitic. 

2.  Syphilitic  parents  may  bring  forth  healthy  children. 

3.  If  a  mother,  healthy  at  procreation,  bears  a  child  syph- 
ilitic from  the  father,  the  mother  must  have  latent  pox  or 
must  be  immune,  having  become  infected  through  the  pla- 
cental circulation.  She  often  shows  no  symptoms,  having 
received  the  poison  gradually  in  the  blood,  and  having  thus 
received,  it  may  be  said,  preventive  inoculations.  Certain  it 
is  that  mothers  are  almost  never  infected  by  suckling  their 
own  syphilitic  children  (Colles's  law). 

4.  If  both  parents  were  healthy  at  the  time  of  procreation, 
and  the  mother  afterward  contracts  .syphilis,  the  child  may 
become  .syphilitic,  and  the  earlier  in  the  pregnancy  the 
mother  is  diseased,  the  more  certain  is  the  child  to  be 
tainted.     This  is  known  as  "  infection  in  utero." 

5.  The  more  recent  the  parental  syphilis,  the  more  certain 
is  infection  of  the  offspring.  The  children  are  often  .still- 
born, 

*  Pathology  and  Treatment  of  Syphilis. 


SYPHILIS.  189 

6.  When  the  disease  is  latent  in  the  parents  it  is  apt  to  be 
tardy  in  the  children. 

7.  The  longer  the  time  which  has  passed  since  the  dis- 
appearance of  parental  symptoms,  the  more  improbable  is 
infection  of  the  children. 

8.  In  most  instances  parental  syphilis  grows  weaker,  and 
after  the  parents  beget  some  tainted  children  they  bring 
forth  healthy  ones. 

Many  women  who  labor  under  hereditary  syphilis  are 
sterile.  Many  s}'philitic  women  abort,  usually  before  the 
eighth  month.  The  foetus  very  often  dies  at  an  early  period 
of  gestation.  This  may  be  due  to  a  gummatous  placenta 
or  to  a  degeneration  of  placental  follicles. 

Evidences  of  Hereditary  Syphilis  (manifest  at,  or  oftener 
soon  after,  birth). — Hutchinson  says  that  at  birth  the  skin 
is  almost  invariably  clear.  In  a  few  weeks  "  snuffles  "  begin, 
which  are  soon  followed  by  a  skin-eruption,  by  body-wasting, 
and  by  a  chain  of  secondary  symptoms  (iritis,  mucous  patches, 
pains,  condylomata,  etc.).  The  child  looks  like  a  withered-up 
old  man.  Eruptions  are  met  with  on  the  palms  and  soles. 
Intertrigo  is  usual.  Cracks  occur  at  the  angles  of  the  mouth, 
and  leave  permanent  radiating  scars.  The  abdomen  is  tumid, 
and  there  is  apt  to  be  exhausting  diarrhoea.  Atrophic  lesions 
may  appear  in  the  bones.  In  the  skull  the  bone  may  be 
softened  by  removal  of  its  salts  or  be  thinned  by  the  pressure 
of  the  brain.  In  the  long  bones  the  epiphyseal  ends  suffer, 
the  attachment  of  epiphysis  to  shaft  is  weak,  and  separation 
is  easily  induced.  Suppuration  of  the  epiphysis  is  common. 
Osteophytic  lesions  of  the  skull  are  shown  by  symmetrical 
spots  of  thickening  upon  the  parietal  and  frontal  bones  (nati- 
form  skulls).  In  the  long  bones  osteophytes  are  frequently 
formed.  A  child  with  precocious  hereditary  syphilis  is  apt 
to  die,  but  if  it  lives  from  six  months  to  one  year  the  symp- 
toms for  a  time  disappear  and  for  years  the  disease  may  be 


190  A   MANUAL    OF  SURGERY. 

latent.  When  the  disease  begins  again  the  symptoms  are 
various,  namely :  noises  in  the  ears,  often  followed  by  deaf- 
ness ;  interstitial  keratitis ;  dactylitis  (specific  inflammation 
of  all  the  structures  of  a  finger);  synovitis  in  any  joint; 
ossifying  nodes  ;  developmental  osseous  defects  ;  suppurative 
periostitis;  ulcerations;  death  of  bone ;  falling  in  of  nose; 
nervous  maladies ;  occasionally  sarcocele,  etc. 

Diagnosis. — In  the  diagnosis  of  hereditary  syphilis  the 
condition  of  the  teeth  is  of  much  importance  :  the  temporary 
teeth  decay  soon,  but  present  no  characteristic  defect.  If  the 
upper  permanent  central  incisors  are  examined,  other  teeth 
may  show  defects,  but  in  these  alone  are  defects  almost  sure 
to  appear.  In  hereditary  syphilis  they  present  an  appearance 
of  marked  deviation  from  health,  and  are  called  "  Hutchin- 
son teeth"  (PI.  I,  Fig.  4).  If  they  are  dwarfed,  too  short 
and  too  narrow,  and  if  they  display  a  single  central  cleft  in 
their  free  edge,  then  the  diagnosis  of  syphilis  is  almost  cer- 
tain. If  the  cleft  is  present  and  the  dwarfing  absent,  or  if 
the  peculiar  form  of  dwarfing  be  present  without  any  con- 
spicuous cleft,  the  diagnosis  may  still  be  made  with  much 
confidence.  In  early  infancy  the  diagnosis  is  made  by  the 
snuffles,  broad  nose,  skin-eruptions,  wasted  look,  sores  at 
the  mouth-angles,  tenderness  over  bones,  condylomata,  and 
history  of  the  parents.  The  diagnosis  at  a  later  period  is 
made  by  the  existence  of  symmetrical  interstitial  keratitis, 
deafness  which  comes  on  without  pain  or  running  from  the 
ear,  ossifying  nodes,  white  radiating  scars  about  the  mouth- 
angles,  sunken  nose,  natiform  skull,  deformity  of  long  bones, 
suppuration  of  epiphyses,  and  Hutchinson  teeth.  It  must  be 
remembered  that  a  child  apparently  born  healthy  and  pre- 
senting no  secondary  symptoms  may  show  bone  disease, 
keratitis,  or  syphilitic  deafness  at  puberty. 

Treatment. — In  infants  inunctions  are  to  be  used  until  the 
symptoms   disappear,  but  mercury  must   not  be  forced  or 


TUMORS   OR   MORBID    GROWTHS.  I9I 

continued  too  long  after  the  symptoms  are  gone.  There 
must  be  rubbed  into  the  sole  of  each  foot  or  the  palm  of 
each  hand  5  grains  of  mercurial  ointment  every  morning 
and  night.  Brodie  advised  spreading  the  ointment  (in  the 
strength  of  3j  to  the  ounce)  upon  flannel  and  fastening  it 
around  the  child's  belly.  If  the  skin  is  so  tender  that  mer- 
cury must  be  given  by  the  mouth,  White  and  Hearn  advise 
that  gr.  yV  ^o  g^-  \  °^  niercur}^  with  chalk  with  i  grain  of 
sugar  be  taken  three  times  a  day  after  nursing.  If  tertiary 
symptoms  appear,  or  in  any  case  when  the  secondaries  dis- 
appear, give  gr.  ss  to  gr.  j  or  more  of  iodide  of  potassium 
several  times  a  day  in  syrup.  White  advocates  the  continu- 
ance of  the  mixed  treatment  intermittently  until  puberty. 
Local  lesions  require  local  treatment  as  in  the  adult.  A 
syphilitic  child  must  be  nursed  by  its  mother,  as  it  will 
poison  a  healthy  nurse.  If  the  mother  cannot  nurse  the 
child,  it  must  be  brought  up  on  the  bottle.  For  the  cachexia 
use  cod-liver  oil,  iodide  of  iron,  arsenic,  and  the  phosphates. 

XVI.   TUMORS   OR   MORBID    GROWTHS. 

Division. — Morbid  growths  are  divided  into  (i)  neoplasms 
and  (2)  cysts. 

Neoplasms. — A  neoplasm  is  a  pathological  new  growth 
which  tends  to  persist  independently  of  the  structures  in 
which  it  lies,  and  which  performs  no  physiological  function. 
A  hypertrophy  is  differentiated  from  a  tumor  by  the  facts 
that  it  is  a  result  of  increased  physiological  demands  or  of 
local  nutritive  changes  and  that  it  tends  to  subside  after  the 
withdrawal  of  the  exciting  stimulus.  Further,  a  hypertrophy 
does  not  destroy  the  natural  contour  of  a  part,  while  a  tumor 
does.  Inflammation  has  marked  symptoms :  its  swelling 
does  not  tend  to  persist,  it  terminates  in  resolution,  organ- 
ization, or  suppuration,  and  the  microscope  differentiates  it 
from  tumor.     Inflammation,  too,  has  an  assignable  exciting 


192  A   MANUAL    OF  SURGERY. 

cause.  A  new  growth  means  a  mass  of  new  tissue  ;  hence  it 
is  improper  to  designate  as  tumors  those  sweUings  due  to 
extravasation  of  blood  (as  in  haematocele)  or  of  urine  (from 
ruptured  urethra),  to  displacement  of  parts  (as  in  hernia, 
floating  kidney,  or  dislocation  of  the  liver),  or  to  fluid  dis- 
tention of  a  natural  cavity  (as  in  hydrocele  or  bursitis). 

Classes  of  Tumors. — There  are  two  classes  of  tumors  : 
the  first  class  includes  those  derived  from  or  composed  of 
ordinary  connective  tissue  or  of  higher  structures.  These 
all  originate  from  cells  which  are  developed  from  the  meso- 
blast.  There  are  two  groups  of  connective-tissue  tumors : 
(a)  the  typical  benign  or  innocent,  which  find  their  type  in 
the  healthy  adult  human  body  ;  and  {p)  the  atypical  or  malig- 
nant, which  find  no  counterpart  in  the  healthy  adult  human 
body,  but  rather  in  the  immature  connective  tissues  of  the 
embryo. 

The  second  class  of  tumors  includes  those  which  are 
derived  from  or  composed  of  epithelium :  [a)  the  typical, 
composed  of  adult  epithelium  ;  and  (J?)  the  atypical,  com- 
posed of  embryonic  epithelium. 

Midler  s  Lazv. — M tiller's  law  is  that  the  constituent  ele- 
ments of  neoplasms  always  have  their  types,  counterparts, 
or  close  imitations  in  the  tissues  of  a  normal  organism,  either 
embryonic  or  mature. 

Virchows  Lazv. — Virchow's  law  is  that  the  cells  of  a  tumor 
spring  from  pre-existing  cells  (hence  there  is  no  special 
tumor-cell  or  cancer-cell). 

The  term  "  heterologous  "  is  no  longer  used  to  signify  that 
the  cellular  elements  of  a  tumor  have  no  counterpart  in  the 
healthy  organism,  but  is  employed  to  signify  that  a  tumor 
deviates  from  the  type  of  the  structure  from  which  it  takes 
its  origin  (as  a  chondroma  arising  from  the  parotid  gland). 
Tumors  when  once  formed  almost  invariably  increase  and 
persist,    though    occasionally    warts,    exostoses,    and    fatty 


TUMORS   OR   MORBID    GROWTHS.  1 93 

tumors  do  disappear.  Tumors  may  ulcerate,  inflame,  slough, 
be  infiltrated  with  blood,  or  undergo  mucoid,  calcareous,  or 
fatty  degeneration. 

Causes. — The  causes  of  tumors  are  not  positively  recog- 
nized, those  alleged  being  but  theories  varying  in  probability 
and  ingenuity. 

TJic  incltLsion  tliavy  of  Cohnhehn  supposes  that  more 
embryonic  cells  exist  than  are  needful  to  construct  the  foetal 
tissues,  that  masses  of  them  remain  in  the  tissues,  and  that 
these  may  be  stimulated  later  into  active  growth.  This 
embryonic  hypothesis  seems  to  receive  a  certain  force  from 
the  facts  that  exostoses  do  sometimes  develop  from  portions 
of  unossified  epiphyseal  cartilage,  and  that  tumors  often  arise 
in  regions  where  there  was  a  suppression  of  a  foetal  part, 
closure  of  a  cleft,  or  an  involution  of  epithelium  (epithelioma 
is  usual  at  muco-cutaneous  junctures).  This  theory,  which 
does  not  explain  the  origin  of  most  neoplasms,  cannot  suc- 
cessfully be  maintained  even  as  a  common  predisposing  cause. 

Hcreditation  is  extremely  doubtful.  S.  W.  Gross  found 
hereditary  influence  by  no  means  always  apparent  in  cancer 
of  the  breast.  It  is  affirmed  by  some,  denied  by  others,  and 
doubted  by  a  number.  At  most,  hereditary  influence  can 
only  predispose. 

Injury  and  inflammation  may  undoubtedly  prove  exciting 
causes.  A  blow  is  not  infrequently  followed  by  sarcoma ; 
the  irritation  of  a  hot  pipe-stem  may  excite  cancer  of  the  lip ; 
the  scratching  of  a  jagged  tooth  may  cause  cancer  of  the 
tongue ;  chimney-sweeps'  cancer  arises  from  the  irritation 
of  dirt  in  the  scrotal  creases ;  and  warts  often  arise  from 
constant  contact  with  acrid  materials. 

Physiological  activity  favors  the  development  of  sarcoma, 
and  physiological  decline  favors  the  development  of  cancer. 

Parasitic  Influence. — This  theory  does  not  maintain  that 
the  tumor  is  the  parasite,  but  that  it  contains  the  parasite. 

13 


194  A   MANUAL    OF  SURGERY. 

Some  facts  render  a  parasitic  origin  of  malignant  growths  not 
improbable ;  as,  for  instance,  the  likeness  of  some  tumors  to 
infective  granulomata,  their  occasional  secondary  development 
in  distant  parts  of  the  body,  the  resemblance  of  the  secondary 
to  the  primary  growths,  and  the  tenacity  of  their  persistence. 
It  is  only  just  to  state,  however,  that  tumors  do  not  seem 
to  be  hetero-inoculable.  A  parasitic  origin  of  cancer  is 
pointed  to  by  its  geographical  distribution,  the  disease  being 
very  common  in  low  and  marshy  districts  (Havilland). 

Actinomycosis,  long  thought  to  be  a  true  tumor,  is  now 
known  to  arise  from  the  ray-fungus.  There  can  be  no  doubt 
that  changes  in  the  liver  which  practically  constitute  a  new 
growth  can  arise  from  the  growth  of  a  cell  called  by  Darier 
the  "  psorosperm."  A  disease  due  to  psorosperms  is  called 
a  "psorospermosis."  It  is  affirmed  by  some  that  molluscum 
contagiosum,  follicular  keratosis,  cancer,  and  Paget's  disease 
are  due  to  psorosperms.  Some  claim  to  find  the  parasite  in 
all  cases  of  cancer,  while  others  can  find  it  in  only  four  or 
five  per  cent,  of  the  cases. 

Heneage  Gibbes  affirms^  that  dilatation  of  the  bile-ducts 
of  a  rabbit's  liver  is  caused  by  the  chronic  irritation  arising 
from  multiplication  of  the  coccidium  oviforme  in  them,  and 
not  in  the  columnar  cells  of  the  bile-ducts,  as  has  been  stated  ; 
and,  further,  that  the  large  majority  of  glandular  cancers 
show  nothing  that  can  be  considered  parasitic,  the  suspicious 
appearances  noted  in  some  {qv^  cases  being  due  to  endoge- 
nous cell-formation.  This  coccidium  oviforme  is  a  genus  of 
the  sporozoa,  class  protozoa,  the  lowest  division  of  the  animal 
kingdom.     To  this  class  belong  the  monera  and  infusoria. 

Malignant  and  Innocent  or  Benign  Tumors. — Malignant 
growths  infiltrate  the  tissues  as  they  grow;  benign  tumors 
only  push  the  tissues  away  ;  hence  malignant  tumors  are 
not    thoroughly    encapsuled,    while    innocent    tum.ors    are 

^  The  American  Journal  of  Medical  Sciences,  July,  1893. 


TUMORS   OR  MORBID   GROWTHS.  1 95 

encapsuled.  Malignant  tumors  grow  rapidly ;  innocent 
tumors  grow  slowly.  Malignant  tumors  become  adherent 
to  the  skin  and  cause  ulceration ;  innocent  tumors  rarely 
adhere  and  rarely  cause  ulceration.  Many  malignant  tumors 
give  rise  to  secondary  growths  in  adjacent  lymphatic  glands 
(cancer,  except  in  the  stomach,  gullet,  and  upper  jaw,  always 
so  tends) ;  sarcoma  does  not  cause  them,  unless  it  be  mel- 
anotic or  unless  it  arises  from  the  testicle  or  tonsil.  Inno- 
cent tumors  never  cause  secondary  lymphatic  involvement, 
although  the  glands  near  the  tumor  may  enlarge  from 
accidental  inflammatory  complications.  The  malignant  tu- 
mors, especially  certain  sarcomata  and  soft  cancers,  may  be 
followed  by  secondary  growths  in  distant  parts  and  various 
structures  (bones,  viscera,  brain,  muscles,  etc.);  innocent 
tumors  are  not  followed  by  these  secondary  reproductions, 
although  multiple  fatty  tumors  or  multiple  lymphomata  may 
exist.  Malignant  tumors  destroy  the  general  health ;  inno- 
cent tumors  do  not.  Malignant  tumors  tend  to  recur  after 
removal ;   innocent  tumors  do  not  if  operation  was  thorough. 

Classification. — Tumors  may  be  classified  as  follows  : 

I.  Connective-tissue  tumors. 

1.  Innocent  tumors,  or  those  composed  of  mature  con- 

nective tissue  : 
Lipomata,  or  fatty  tumors ;  fibromata,  or  fibrous  tu- 
mors ;  cliondroniata,  or  cartilaginous  tumors ;  osteo- 
iiiata,  or  bony  tumors  ;  odoutoinata,  or  tooth-tumors; 
myxomata,  or  mucous  tumors  ;  myoniata,  or  muscle- 
tumors  ;  neuromata,  or  tumors  upon  nerves  ;  angcio- 
mata,  or  tumors  formed  of  blood-vessels  ;  lymplian- 
gciomata,  or  tumors  formed  of  lymphatic  vessels ; 
and  lympJiomata,  or  tumors  of  lymphatic  glands. 

2.  Malignant  tumors,  or  those  composed  of  embryonic 

connective-tissue  : 
Sarcomata. 


196  A   MANUAL    OF  SURGERY. 

II.  Epithelial  tumors. 

1.  Innocent  tumors,  or  those  composed  of  mature  epi- 

thelial tissue : 
Adenomata,  or  tumors  whose  type  is  a  secreting  gland  ; 
and  papilloniata,  or  tumors  whose  type  is  found  in 
the  papillae  of  skin  and  mucous  membranes. 

2.  Malignant  tumors,  or  those  composed  of  embryonic 

epithelial  tissue : 
Carcinomata,  or  cancers. 

I.  Innocent  Connective-tissue  Tumors. — The  growths 
mimic  or  imitate  some  connective  tissue  or  higher  tissue  of 
the  mature  and  healthy  organism. 

Lipomata  are  tumors  composed  of  fat  contained  in  the 
cells  of  connective  tissue,  which  cells  are  bound  together 
by  fibres.  If  the  fibres  are  excessively  abundant,  the  growth 
is  spoken  of  as  a  "  fibro-fatty  tumor."  A  fatty  tumor  has 
a  distinct  capsule,  tightly  adherent  to  surrounding  parts,  but 
loosely  attached  to  the  tumor ;  hence  enucleation  is  easy. 
Fibrous  trabeculae  run  from  the  capsule  of  a  subcutaneous 
lipoma  to  the  skin ;  hence  movement  of  the  integument  over 
the  tumor  or  of  the  tumor  itself  causes  dimpling  of  the  skin. 
Lipomata  are  most  frequent  in  middle  life,  and  their  com- 
monest situations  are  in  the  subcutaneous  tissues  of  the  back 
or  of  the  dorsal  surfaces  of  the  limbs  ;  they  usually  occur 
singly,  but  may  be  multiple  and  sometimes  symmetrical. 
A  lipoma  is  soft,  doughy,  mobile,  lobulated,  of  uniform  con- 
sistence, and  may  give  on  tapping  a  tremor  or  pseudo- 
fluctuation.  The  skin  over  a  fatty  tumor  sometimes  ulcerates 
from  pressure  ;  the  tumor  itself  may  inflame  or  partly  calcify. 
When  a  lipoma  has  once  inflamed,  it  becomes  immovable. 
The  commonest  situation  for  lipomata  is  in  the  subcutaneous 
layer  of  fat.  Subcutaneous  lipoma  of  the  palm  of  the  hand 
or  sole  of  the  foot  resembles  a  compound  ganglion,  and  it  is 
apt  to  be  congenital.     Lipomata  of  the  head  and  face  are 


TUMORS   OR   MORBID    GROWTHS.  1 97 

rare.  In  the  subcutaneous  tissues  of  the  groins,  neck, 
pubes,  axillae,  or  scrotum  a  mass  of  fat  may  form,  unlimited 
by  a,  capsule  and  known  as  a  "diffuse  lipoma."  A  naevo- 
lipoma  is  a  nsevus  with  much  fibro-fatty  tissue.  Fatty 
tumors  may  arise  in  the  subserous  tissue,  and  when  arising 
in  either  the  femoral  or  inguinal  canals  or  the  linea  alba 
they  resemble  omental  herniae  and  are  spoken  of  as  "  fat- 
herniae."  In  the  retroperitoneal  tissues  enormous  fibro-fatty 
tumors  occasionally  grow,  and  these  neoplasms  tend  to 
become  sarcomatous.  Lipomata  may  arise  from  beneath 
synovial  membranes  and  will  project  into  the  joints,  being 
still  covered  by  synovial  membrane.  Fatty  tumors  occa- 
sionally arise  in  submucous  tissues,  between  or  in  muscles, 
from  periosteum,  and  from  the  meninges  of  the  spinal  cord 
(Bland  Sutton). 

Treatment. — A  single  subcutaneous  lipoma  is  to  be  re- 
moved. Open  the  capsule,  tear  out  or  dissect  out  the  mass, 
and  always  drain  for  twenty-four  hours,  or  butyric  fermenta- 
tion will  be  apt  to  occur.  Multiple  subcutaneous  lipomata, 
if  very  numerous,  should  not  be  interfered  with  unless 
troublesome  because  of  their  size  or  situation,  when  they 
should  be  removed.  Diffuse  lipomata  cannot  be  removed 
entirely,  and  operation  is  useless.  Liquor  potassae  has  been 
recommended  to  limit  growth ;  it  is  to  be  taken  internally 
for  a  considerable  time,  but  it  seems  to  be  useless.  Sub- 
peritoneal lipomata  are  never  diagnosticated  until  the  belly 
has  been  opened  or  the  growth  has  been  removed. 

Fibromata  are  tumors  composed  of  wavy  fibrous  bundles. 
A  fibroma  has  no  distinct  capsule,  though  surrounding  tis- 
sues are  so  compressed  as  to  simulate  a  capsule.  Fibromata 
are  most  usual  in  young  adults,  but  they  may  occur  at  any 
period  of  life,  and  are  hard  and  movable.  Pure  fibromata, 
which  are  rare,  are  generally  solitary,  grow  slowly,  are  of 
uniform  consistence,  and  have  not  much  circulation.     Soft 


198  A   MANUAL    OF  SURGERY. 

fibromata  grow  more  rapidly  than  do  the  hard,  may  become 
quite  large,  are  apt  to  have  distinct  pedicles,  and  arise  gen- 
erally from  the  scrotum,  labia,  uterus,  and  on  the  inner  sur- 
face of  the  arm  or  the  thigh.  Hard  fibromata  grow  slowly ; 
they  may  form  upon  nerves,  they  may  arise  in  the  mammary 
gland,  and  they  may  spring  from  various  fibrous  membranes, 
from  the  periosteum  of  the  nasal  bones  (fibrous  polypi),  and 
from  the  gums  (fibrous  epulides).  Fibromata  may  become 
cystic,  calcareous,  osseous,  or  sarcomatous. 

A  painful  subcutaneous  tubercle,  which  is  a  form  of  fibroma 
commonest  in  females,  arises  in  the  subcutaneous  cellular 
tissue,  usually  of  the  extremities.  It  is  firm,  very  tender, 
movable,  rarely  larger  than  a  pea,  and  the  skin  over  it  seems 
healthy.  Violent  pain  occurs  in  paroxysms  and  radiates 
over  a  considerable  area  of  which  the  tubercle  is  the  centre. 
These  paroxysms  may  occur  only  once  in  many  days  or 
many  times  in  one  day.  Nerve-fibrillae  have  never  been 
found  in  these  tubercles. 

Fibrous  epulis  is  a  fibroma  arising  from  the  gums  or  peri- 
odontal membrane  (Bland  Sutton)  in  connection  with  a 
carious  tooth  or  retained  snag;  it  is  covered  by  mucous 
membrane,  grows  slowly,  may  attain  a  large  size,  and  some- 
times has  a  stem,  but  is  more  often  sessile.  It  may  undergo 
myxomatous  change  or  may  become  sarcomatous.  Fibrous 
tumors  may  arise  from  the  ovary,  the  intestine,  and  the  lar- 
ynx. Pure  fibromata  of  the  uterus  are  very  rare,  but  fibro- 
myomata  are  very  common  (see  Myomata,  p.  204) ;  hence 
the  term  "  uterine  fibroid  "  should  be  abandoned. 

Molluscum  jibrosum  is  an  overgrowth  of  the  fibrous  tissue 
of  both  skin  and  subcutaneous  structure.  It  may  be  limited 
or  widely  extended  ;  'it  may  appear  as  an  infinite  number  of 
nodules  scattered  over  the  entire  body  or  as  hanging  folds 
of  fibrous  tissue  in  certain  areas.  Keloid  is  a  hard  fibrous 
growth  arising  in  scar-tissue ;  it  is  crossed  by  pink,  white, 


TUMORS   OR   MORBID    GROWTHS.  1 99 

or  discolored  ridges,  and  is  named  from  a  fancied  likeness 
to  the  crab.  It  is  more  common  in  negroes  than  in  whites, 
and  is  most  frequent  in  the  cicatrices  of  burns,  though  it  may 
arise  in  the  scar  of  any  injury,  as  the  scar  from  piercing  the 
ears,  and  in  the  scars  of  syphihtic  lesions,  small-pox,  or 
vaccination.  It  is  rare  in  early  childhood  and  in  old  age. 
It  grows  slowly,  lasts  for  many  years,  and  may  eventually 
undergo  involution  and  disappear. 

]\Ioyph(jca,  or  spontaneous  keloid,  is  a  name  used  to  desig- 
nate a  growth  of  this  description  which  does  not  arise  from 
a  scar ;  but  it  seems  certain  that  scar-tissue  was  present, 
though  possibly  in  small  amount  from  trivial  injury. 

Treatment. — Enucleate  fibromata;  do  not  let  them  remain, 
as  any  fibrous  tumor  might  become  a  sarcoma.  Epulis  requires 
the  cutting  away  of  the  entire  mass,  the  removal  of  the 
related  snag  or  carious  tooth,  and  sometimes  the  biting  away 
of  a  portion  of  the  alveolus  with  a  rongeur  forceps.  Keloid 
should  not  be  operated  upon  :  it  will  only  return,  and  will 
also  recur  in  the  stitch-holes.  Trust  to  time  for  involution, 
or  use  pressure  with  flexible  collodion,  by  which  method 
Prof  DaCosta  cured  a  case  following  small-pox. 

Chondromata  (enchondromata)  are  tumors  formed  either 
of  hyaline  cartilage,  of  fibro-cartilage,  or  of  both.  Chondro- 
mata are  apt  to  occur  in  the  long  bones,  the  pelvis,  the  rib-car- 
tilages, and  the  bones  of  the  hands  or  feet,  and  often  spring 
from  unossified  portions  of  epiphyseal  cartilage.  They  may 
be  single  or  multiple,  are  often  nodulated,  and  are  most  com- 
monly met  with  in  the  young.  They  have  distinct  adherent 
capsules  ;  they  grow  slowly,  progressively  hollowing  out  the 
bones  by  pressure ;  they  cause  no  pain  ;  they  impart  a  sen- 
sation of  firmness  to  the  touch,  unless  mucoid  degeneration 
forms  zones  of  softness  or  fluctuation  ;  they  are  inelastic, 
smooth  or  nodular,  immovable,  and  often  ossify.  Chondro- 
mata may  grow  to  an  enormous  size.     A  chondroma  of  the 


200  A   MANUAL    OF  SURGERY. 

parotid  ^land  or  testicle  always  contains  sarcomatous  ele- 
ments, and  any  chondroma  may  become  a  sarcoma.  Chon- 
dromata  are  notably  frequent  in  persons  who  had  rickets  in 
early  life.  Eccliondroscs^  which  are  '*  small  local  overgrowths 
of  cartilage  "  (Bland  Sutton),  arise  from  articular  cartilages, 
especially  of  the  knee-joint,  and  from  the  cartilages  of  the 
larynx  and  nose.  Loose  or  floating  cartilages  in  the  joints 
may  be  broken-off  ecchondroses  or  portions  of  hyaline  car- 
tilage which  are  entirely  loose  or  are  held  by  a  narrow  stalk, 
and  which  arise  by  chondrification  of  villous  processes  of  the 
synovial  membrane ;  only  one  or  vast  numbers  may  exist ; 
one  joint  may  be  involved,  or  several  ;  they  may  produce 
no  symptoms,  but  usually  produce  from  time  to  time  violent 
pain  and  immobility  by  acting  as  a  joint-wedge. 

Treainient. — Remove  chondromata  whenever  possible,  for, 
if  allowed  to  remain  undisturbed,  they  are  apt  to  resent 
this  hospitality  by  becoming  sarcomatous.  Incise  the  cap- 
sule and  take  away  the  growth,  using  chisels  and  gouges 
if  necessary.  Incomplete  removal  means  inevitable  recur- 
rence. Amputation  is  very  rarely  demanded.  Loose  bodies 
in  the  joints,  if  productive  of  much  annoyance,  are  to  be 
removed,  the  joint  being  opened  with  the  strictest  antiseptic 
care. 

Osteomata. — Bland  Sutton  says  that  osteomata  are  ossify- 
ing chondromata.  Compact  osteomata,  which  are  identical 
in  structure  with  the  compact  tissue  of  bone,  occur  in  the 
frontal  sinus,  mastoid  process,  external  auditory  meatus,  and 
in  other  regions  in  those  beyond  middle  life ;  they  are  small, 
capped  with  cartilage,  smooth,  round,  with  small,  occasion- 
ally cartilaginous  bases,  and  are  densely  hard. 

Cancellous  osteomata,  which  comprise  the  great  majority 
of  bone-tumors,  are  similar  in  structure  to  cancellous  bone. 
They  spring  from,  and  are  crusted  with,  cartilage ;  they  may 
have  fibrous  capsules,  and  are  often  movable  when  recent, 


TUMORS   OR  MORBID    GROWTHS.  201 

but  soon  become  fixed ;  they  have  a  broad  base,  are  angled, 
nodular,  firm  (but  not  so  har-d  as  are  the  compact  osteomata), 
painless  except  by  pressure,  occur  particularly  at  the  ends 
of  long  bones,  may  grow  to  large  size,  and  are  commonest 
in  youth.  Osteomata  near  joints  become  overlaid  by  bursae 
which  in  rare  instances  communicate  with  their  related  joints. 

The  term  exostosis  has  been  used  as  being  synonymous 
with  osteomata,  but  wrongly  so,  as  an  exostosis  is  an  irregu- 
lar, local,  bony  growth  which  does  not  tend  to  progress 
beyond  a  certain  point,  and  which  is  hence  not  a  tumor. 
A  true  exostosis  is  seen  in  the  ossification  of  a  tendon-inser- 
tion, in  a  limited  growth  from  the  maxillary  bones,  and  in  a 
local  growth  from  the  last  phalanx  of  the  big  toe,  which 
growth  is  known  as  a  "  sub-ungual  exostosis."  The  bony 
masses  sometimes  found  in  the  brain,  lungs,  testicle,  various 
glands,  and  tumors  are  not  true  osteomata. 

Treatment.  — Osteomata  which  are  non-productive  of  pain 
or  trouble  do  not  demand  removal.  If  they  produce  pain 
by  pressure,  if  they  press  upon  important  structures,  if  they 
produce  annoying  deformities,  or  if  they  grow  rapidly,  then 
remove  them  by  means  of  chisels,  gouges,  or  by  the  surgical 
engine.  Exostosis  of  the  toe  should  always  be  removed,  to 
do  which  the  nail  should  be  split  and  part  of  it  taken  away, 
and  the  bony  mass  be  gouged  away  or  be  cut  off  with  forceps. 

Odontomata  ^  are  tumors  composed  of  tooth-tissue  and 
springing  from  the  germs  of  teeth  or  from  developing  teeth. 
Bland  Sutton  divides  them  into  (i)  those  springing  from  the 
follicle;  (2)  those  springing  from  the  papilla;  and  (3)  those 
springing  from  the  whole  germ. 

EpitJielial  odontomes,  or  imiltilocular  cystic  tnmors^  arise 
from  the  follicle,  occur  oftenest  in  the  lower  jaw,  dilate  the 
bone,  have  capsules,  and  are  made  up  of  masses  of  cysts 

^  This  section  is  abridged  from  Bland  Sutton's  striking  chapter  upon  odontomes 
in  his  recent  work  on  Tumors. 


202  A   MA A^ UAL    OF  SURGERY. 

which  are  filled  with  brown  fluid.  These  cysts  are  met 
with  most  frequently  before  the  age  of  twenty.  Follicular 
odofitonics,  or  dciitigcroiis  cysts,  oftcnest  spring  from  the 
follicles  of  the  permanent  molars.  In  a  dentigerous  cyst 
there  exists  an  expanded  follicle  which  distends  the  bone,  the 
follicle  being  filled  with  thick  fluid  and  containing  a  portion 
of  a  tooth.  A  fibrous  odontonie  is  due  to  thickening  of  the 
tooth-sac,  thus  preventing  eruption  of  the  tooth ;  fibrous 
odontomes  are  usually  multiple,  and  are  apt  to  occur 
in  rickety  children.  A  ccnicntome  is  due  to  enlargement, 
thickening,  and  ossification  of  the  capsule,  the  developing 
tooth  being  encased  in  cement.  A  compound  follicular  odon- 
tome  is  due  to  ossification  of  portions  only  of  an  enlarged 
and  thickened  capsule,  and  the  tumor  contains  bits  of 
cementum,  portions  of  dentine,  or  small  misshapen  teeth. 
A  radicular  odontomc  springs  from  the  papilla  and  arises  after 
the  crown  of  the  tooth  is  formed  and  while  the  roots  are 
forming ;  hence  it  contains  dentine  and  cement,  but  no 
enamel.  Composite  odontomes  are  formed  of  irregular  shape- 
less masses  of  dentine,  cement,  and  enamel.  All  the  above 
forms  occur  in  man.  They  present  themselves  as  hard 
tumors  associated  with  teeth  or  in  an  area  where  teeth  have 
not  erupted.  They  may  distend  the  jaw.  Occasionally  an 
odontome  simulates  necrosis;  it  is  surrounded  by  pus,  and  a 
sinus  forms. 

Treatment. — The  diagnosis  is  scarcely  ever  made  until 
after  incision ;  hence,  be  in  no  haste  to  excise  large  por- 
tions of  bone  for  a  doubtful  growth  ;  incise  first  and  see  if 
it  be  an  odontome,  which  requires  only  the  removal  of  an 
implicated  tooth,  curetting  with  a  sharp  spoon,  and  packing 
with  iodoform  gauze. 

Myxomata  are  tumors  composed  of  mucous  tissue.  The 
tissue  type  of  these  tumors  is  found  in  the  vitreous  humor 
of  the  eye  and  in  the  perivascular  tissues  of  the  umbilical 


TUMORS   OR  MORBID    GROWTHS.  203 

cord.  Bovvlby  states  that  myxomata  are  in  reality  soft 
fibromata  whose  intercellular  substance  has  been  replaced 
by  mucin.  Myxomata  may  result  from  myxomatous  degen- 
eration of  cartilage,  of  muscle,  or  of  fibrous  tissue.  These 
tumors  are  soft,  elastic,  usually  pedunculated,  tremulous,  and 
vibratory.  Cutting  into  them  causes  a  straw-colored  fluid  to 
exude  ;  they  grow  slowly,  have  but  little  circulation,  and  their 
diagnosis  may  be  impossible  before  removal.  Some  patholo- 
gists place  myxomata  among  the  malignant  tumors,  but  most 
consider  them  as  benign  tumors,  though  they  tend  strongly 
to  become  sarcomatous  (myxosarcomata).  A  sarcoma  may 
undergo  myxomatous  degeneration. 

Myxomata  may  arise  from  the  skin;  from  the  mucous 
membrane  of  the  nose,  the  frontal  sinus,  the  antrum,  the 
womb,  and  the  tympanum  (gelatinous  polyps) ;  from  the 
parotid  and  mammary  glands;  from  the  subcutaneous  tissue, 
the  nerve-sheaths,  the  intermuscular  septi,  the  rectum,  and 
the  bladder  (polyps). 

Nasal  polypi  grow  from  the  mucous  membrane  over  the 
turbinated  bones;  they  are  soft  and  jelly-like,  of  a  grayish 
color,  and  have  stems  or  pedicles ;  they  may  be  seen 
through  the  anterior  nares,  may  project  behind  the  veil 
of  the  palate,  and  may  bulge  out  the  passages  of  the  nose  ; 
they  may  be,  and  usually  are,  multiple ;  they  may  be  present 
in  one  nasal  fossa  or  in  both  ;  and  they  occur  most  com- 
monly in  young  adults. 

Hydatid  moles  of  pregnancy  are  due  to  myxomatous 
changes  in  the  chorion. 

Treatment. — In  treating  myxomata,  remove  them  when- 
ever possible.  Nasal  polyps  may  be  twisted  off  or  be  re- 
moved by  the  wire  snare  or  galvano-cautery. 

Lymphomata  are  tumors  composed  of  lymphatic-gland 
structure,  and  are  due  to  multiplication  of  pre-existing 
adenoid  tissue.     Lymphomata  are  most  frequently  encoun- 


204  A   MANUAL    OF  SURGERY. 

tered  in  the  neck  and  axillae,  and  one  gland  or  many  may  be 
involved ;  they  grow  rapidly  and  attain  a  large  size  ;  they 
are  painless,  are  encapsuled,  and  are  freely  movable  beneath 
the  skin ;  they  do  not  infiltrate  surrounding  tissues,  and 
present  no  thickening  from  inflammation ;  they  are  com- 
monest between  the  ages  of  twenty  and  thirty-five,  but 
they  may  occur  in  early  life.  Gross  states  that  the  enlarge- 
ment usually  begins  upon  one  side  of  the  neck,  gland  after 
gland  being  successively  attacked  ;  in  from  four  to  eighteen 
months  the  glands  of  both  sides  of  the  neck,  the  axillae,  the 
bronchi,  and  the  mesentery  become  involved,  the  patient's 
health  fails,  and  death  soon  ensues.  These  tumors  are  said 
not  to  be  malignant,  but  certain  it  is  that  they  tend  to  recur 
after  removal.  It  is  impossible  to  distinctly  separate  this 
disease  from  lymphadenoma:  they  probably  are  related,  or 
possibly  are  identical.  Sarcoma  of  a  lymphatic  gland  arises 
later  in  life  than  does  lymphoma ;  it  infiltrates  surrounding 
structure,  rendering  the  growth  immovable,  and  implicates 
the  related  glands  only,  gluing  them  together;  the  tumor 
is  painful  and  the  skin  ulcerates.  Lymphoma  differs  from 
tubercular  lymphadenitis  in  many  ways.  It  originates  in 
an  apparently  healthy  person,  it  has  no  tendency  to  sup- 
puration, the  growths  do  not  infiltrate,  they  remain  movable, 
and  the  overlying  skin  retains  a  healthy  appearance. 

Treatment. — If  possible,  entirely  extirpate  a  lymphoma; 
but  if  complete  removal  is  impossible,  perform  no  operation. 
In  inoperable  cases  order  cod-liver  oil  and  nutritious  diet, 
insist  an  open-air  exercise,  employ  inunctions  of  ichthyol, 
give  courses  of  arsenic  in  advancing  doses,  and  from  time  to 
time  administer  iodide  of  potassium  and  iron  in  some  form. 
Fowler's  solution  as  an  injection  into  the  growth  finds  some 
advocates. 

Myomata  are  tumors  composed  of  unstriped  muscle-fibre 
mixed    often    with    fibrous    tissue    (leiomyomataj.     Tumors 


TUMORS   OR  MORBID    GROWTHS.  205 

composed  of  striated  muscle-fibre  (rhabdomyomata)  are  very 
rare  and  are  always  sarcomatous.  Leiomyomata  are  found 
in  the  womb,  in  the  prostate  gland,  in  the  walls  of  the  gullet, 
vagina,  stomach,  bladder,  and  bowel,  in  the  broad  ligament, 
ovary,  and  round  ligament,  in  the  scrotum,  and  in  the  skin. 
Myomata  usually  begin  during  or  after  middle  age  ;  they 
are  encapsuled,  they  grow  slowly,  they  are  firm  and  hard, 
and  they  produce  annoyance  by  their  size  and  weight  or 
by  obstructing  a  viscus  or  channel.  A  leiomyoma  of  the 
posterior  and  middle  of  the  prostate  forms  "  a  middle 
lobe." 

The  so-called  ''  uterine  fibroid  "  is  a  myoma  or  fibromyoma. 
Uterine  myomata  may  originate  within  the  walls  of  the  womb 
(intramural  myomata),  from  the  muscular  structure  of  the 
mucous  lining  (submucous  myomata),  or  from  the  muscular 
tissue  of  the  serous  covering  (subserous  myomata).  Intra- 
mural uterine  myomata  may  be  single  or  be  multiple  and 
may  grow  to  an  enormous  size.  Submucous  myomata  pro- 
ject into  the  cavity  of  the  womb  (fleshy  polyps).  Sub- 
mucous myomata  distend  the  uterus  and  are  often  accom- 
panied by  menorrhagia  or  metrorrhagia ;  they  may  project 
into  the  vagina.  In  some  rare  cases  the  projecting  tumor 
is  detached  by  nature  and  the  patient  is  cured;  in  other  cases 
the  myoma  becomes  gangrenous.  This  form  of  tumor  may 
produce  inversion  of  the  fundus  of  the  womb.  Subserous 
uterine  myomata  cause  trouble  only  by  the  inconvenience 
of  weight  or  the  discomfort  of  pressure.  Uterine  myomata 
may  undergo  fatty,  calcareous,  or  m\-xomatous  change,  and 
may  be  infected  by  septic  organisms  as  a  result  of  the  use 
of  a  uterine  sound  or  of  infection  of  the  pedicle  after 
oophorectomy.  Infection  of  a  uterine  myoma  causes  great 
enlargement,  elevated  temperature,  sweats,  and  exhaustion. 
Uterine  myomata,  which  are  commonest  in  single  women 
(Bland  Sutton),  arise  most  frequently  between  the  ages  of 


206  A   MANUAL    OF  SURGERY. 

twenty-five  and  forty-five.  They  may  never  produce  any 
symptoms ;  some,  by  enlarging  until  they  ascend  above 
the  pelvic  brim,  produce  abdominal  distention ;  some  become 
jammed  or  impacted  in  the  pelvis,  and  produce  by  pressure 
retention  of  urine,  obstruction  to  passage  of  feces,  or  hydro- 
nephrosis. Impaction  may  occur  temporarily  at  each  men- 
strual period.  Many  myomata  produce  uterine  hemorrhage  ; 
some  cause  retroversion  of  the  womb ;  some  protrude  from 
the  cervical  canal ;  some  are  so  large  that  they  cause  dis- 
astrous pressure  upon  the  colon  (constipation),  upon  the 
iliac  veins  (intense  oedema),  or  upon  the  ureters  (hydro- 
nephrosis). Uterine  myomata  usually  shrink  after  the  meno- 
pause. Pregnancy  in  a  myomatous  womb  usually  ends  in 
abortion. 

The  symptoms  of  myomata  of  the  alimentary  canal  are 
similar  to  or  identical  with  the  symptoms  of  malignant 
growths.  Myomata  of  the  skin  are  rare  growths  ;  they  are 
encapsuled,  firm  or  elastic,  and  painless. 

Treatment. — Cutaneous  myomata  are  removed  in  the  same 
manner  as  fatty  tumors.  Uterine  myomata  are  treated  by 
rest,  ergot,  barium  chloride,  and  dilute  sulphuric  acid.  If 
this  treatment  fails  to  arrest  serious  bleeding  due  to  a  fleshy 
polyp,  dilate  the  cervical  canal  and  remove  the  growth.  If 
there  be  dangerous  bleeding  in  a  woman  who  has  some 
years  to  wait  for  the  menopause  and  who  has  not  a  remov- 
able polyp  as  the  cause,  perform  oophorectomy  in  order  to 
bring  on  an  artificial  menopause.  When  a  myoma  becomes 
impacted  at  each  menstrual  period,  remove  the  ovaries  and 
Fallopian  tubes.  Hysterectomy  is  indicated  for  some  very 
large  tumors,  for  tumors  that  grow  after  the  menopause,  and 
for  infected  myomata.  If  the  abdomen  be  opened  to  perform 
oophorectomy,  and  the  tubes  and  ovaries  are  found  so  im- 
plicated in  the  growth  that  they  cannot  be  removed  com- 
pletely, or  the  broad  ligament  is  found  so  drawn  out  that  a 


TUMORS   OR  MORBID    GROWTHS.  20/ 

safe  pedicle  cannot  be  secured,  perform  a  hysterectomy.^  A 
recent  suggestion  for  the  shrinkage  of  uterine  myomata  is 
to  Hgate  both  the  uterine  and  ovarian  arteries.  If  a  myoma 
of  the  prostate  causes  severe  obstruction,  effect  a  suprapubic 
cystotomy  and  remove  the  major  portion  of  the  enlarged 
gland. 

Neuromata. — A  true  neuroma  springs  from  nerve-tissue 
(brain,  cord,  or  nerve-trunks) ;  it  is  composed  of  medullated 
or  non-meduUated  nerve-fibres  which  form  a  plexus  or  net- 
work and  which  are  not  continuous  with  the  fibres  of  the 
nerve-trunk  or  other  area  from  which  the  tumor  grows. 
True  neuromata,  which  are  rare  growths,  arise  during  mid- 
dle life;  they  are  small  in  size,  are  due  to  injury  or  hered- 
itary tendency,  and  they  may  be  single  or  multiple.  There 
is  usually  around  the  tumor,  rather  than  in  it,  severe 
neuralgic  pain,  which  is  greatly  intensified  by  dampness,  by 
blows,  or  by  rough  handling.  The  parts  below  a  neuroma 
are  cold,  swollen,  often  anaesthetic,  and  frequently  present 
motor  paralysis  or  trophic  disorder.  A  false  neuroma  or 
neuro-fibroma  is  a  tumor  growing  from  a  nerve-sheath,  and 
is  identical  in  structure  with  the  sheath.  False  neuromata 
may  be  single,  but  they  are  often  multiple ;  they  may  be  as 
small  as  peas  or  as  large  as  oranges  ;  they  are  smooth  and 
movable,  and  may  cause  great  pain  or  may  only  hurt  when 
pressed  or  struck  ;  they  may  spring  from  roots,  trunks,  or 
branches,  and  they  may  be  linked  with  the  disease  known 
as  "  molluscum  fibrosum."  In  plexiform  neuroma  some 
branches  of  a  nerve  enlarge  and  lengthen  like  an  artery 
in  a  cirsoid  aneurysm  ;  the  mass  feels  like  beads  or  like 
a  bag  of  worms  ;  it  is  mobile,  and  no  pain  is  felt  on  moving 
it ;  and  it  is  generally  congenital.  In  plexiform  neuroma  the 
nerve-sheath    undergoes    myxomatous    change.     Malignant 

1  See  Bland  Sutton's  admirable  article  on  "  Uterine  Myomata"  in  his  work  on 
Tuniors. 


208  A   MANUAL    OF  SURGERY. 

neuroma  means  primary  sarcoma  of  a  nerve-sheath,  though 
any  neuroma  may  become  sarcomatous. 

Traumatic  neuromata  are  occasionally  well  exhibited  after 
nerve-section  or  amputation.  On  nerve-section  the  distal 
end  shrinks  and  atrophies,  the  proximal  end  enlarges  and 
becomes  bulbous.  These  traumatic  neuromata  are  composed 
of  fibrous  tissue  which  contains  nerve-fibres  ;  they  are  usually, 
but  not  alvvays,  painful  on  pressure  or  during  dampness,  and 
they  are  commonest  in  stumps  which  did  not  heal  by  first 
intention.  Painful  subcutaneous  tubercle  is  considered  under 
the  head  of  Fibromata. 

Treatment. — A  false  neuroma  is  to  be  removed,  if  possible, 
without  destroying  the  nerve-trunk.  If,  in  removing  a  neur- 
oma, it  is  necessary  to  exsect  a  portion  of  a  nerve-trunk, 
always  endeavor  to  suture  the  ends  so  as  to  facilitate  resto- 
ration of  function.  For  multiple  neuromata — at  least  should 
the  number  be  large  or  should  molluscum  fibrosum  exist — 
surgery  can  do  nothing.  Plexiform  neuromata  may  often  be 
removed,  but  amputation  may  be  required.  Painful  neuro- 
mata in  stumps  should  be  excised. 

Angeiomata. — These  vascular  or  erectile  tumors  are 
growths  composed  of  blood-vessels. 

Simple  or  capillary  angeiomata,  or  *'  mother's  marks," 
which  affect  the  skin  or  subcutaneous  tissue,  are  composed 
of  enlarged  and  twisted  capillaries  and  of  anastomosing 
vessels  surrounded  by  fat.  These  growths  are  congenital  or 
appear  in  the  first  few  weeks  of  life  ;  they  are  of  a  bright-pink 
color  if  composed  chiefly  of  arterioles,  and  are  bluish  if  com- 
posed mainly  of  venules  ;  they  are  but  little  elevated  ;  they  can 
be  almost  completely  emptied  by  pressure ;  they  occasion- 
ally pass  away  spontaneously,  but  usually  grow  constantly 
and  may  become  cavernous  ;  they  may  ulcerate  and  occasion 
violent  or  fatal  hemorrhage.  One  or  several  large  vessels 
join  a  naevus  to  adjacent  blood-vessels.     Port-wine  or  claret 


TUMORS   OR   MORBID    GROWTHS.  209 

stains  are  pink  or  blue  discolorations  due  to  superficial  naevi 
of  the  skin ;  they  may  be  small  in  extent  or  they  may 
involve  a  very  large  area,  and  are  not  elevated.  Teleangei- 
ectasis  is  a  form  of  naevus  involving  the  skin  and  subcu- 
taneous tissue  in  which  many  arterioles  and  venules  exist. 
Simple  angeiomata  are  common  on  the  forehead,  the  scalp, 
the  face,  the  neck,  the  back,  and  the  extremities.  They  may 
appear  on  the  labiae,  the  tongue,  or  the  lips. 

Cavernous  angeiomata  resemble  in  structure  the  corpora 
cavernosa  of  the  penis ;  there  are  large  spaces  with  thin 
walls  carrying  blood,  and  there  may  be  distinct  vessels  as 
well.  Arteries  send  blood  into  the  spaces,  and  veins  receive 
it  from  the  spaces.  These  channels  and  sinuses  are  enor- 
mously distended  capillaries.  Cavernous  angeiomata  arise  in 
the  skin  and  subcutaneous  tissues  ;  they  are  usually  congeni- 
tal, but  may  develop  from  simple  angeiomata.  These  cav- 
ernous angeiomata  are  purple  or  blue  in  color,  are  distinctly 
elevated,  and  are  apt  to  pulsate ;  they  may  be  emptied  by 
pressure,  and  often  look  like  cysts  with  very  thin  walls. 
Cavernous  angeiomata  may  arise  in  the  breast,  the  tongue, 
or  the  muscles.  If  an  angeioma  contains  an  excess  of  fat, 
the  growth  is  called  a  "  naevoid  lipoma." 

Plexiforin  angeiomata  are  known  as  "cirsoid  aneurysms" 
or  aneurysms  by  anastomosis  (see  p.  231). 

Treatment. — Small  port-wine  stains  can  be  removed  by 
electrolysis,  but  extensive  stains  are  ineffaceable.  Small 
naevi  may  be  ligated  under  hare-lip  pins  ;  larger  naevi  may  be 
strangulated  with  the  Erichsen  suture  or  may  be  completely 
excised.  Excision  is  the  best  plan  for  the  cure  of  the  cav- 
ernous variety  of  angeiomata.  Do  not  use  astringent  in- 
jections. 

Lymphang-eiomata  are  tumors  composed  of  dilated  lymph- 
vessels,  and  are  usually,  though  not  invariably,  congenital. 
The  lymphatic  naevus  is  a  colorless  or  faintly  pink  elevation ; 

14 


2IO  A   MANUAL    OF  SURGERY. 

if  it  is  punctured  with  a  needle,  lymph  flows  from  the  punc- 
ture. One  or  several  naevi  may  be  present  in  the  same 
individual.  Local  lymphangeioma  of  the  tongue  is  mani- 
fested by  a  cluster  of  papillary  projections  containing  lymph. 
Macroglossia  is  a  congenital  enlargement  of  the  anterior 
portion  of  the  tongue,  which  enlargement  grows  more  and 
more  marked  until  finally  the  tongue  is  forced  far  out  of  the 
mouth.  This  condition  of  tongue-enlargement  is  due  to 
lymphangeioma  of  the  mucous  membrane.  Just  as  there 
occur  cavernous  angeiomata  among  blood-vessel  tumors, 
there  occur  cavernous  lymphangeiomata  among  lymph- 
vessel  tumors,  and  the  spaces  are  filled  with  lymph  instead 
of  with  blood. 

Treatment. — Lymphatic  naevus  requires  excision.  In  ma- 
croglossia remove  the  bulk  of  the  mass  by  a  V-shaped  cut 
and  so  stitch  the  mucous  membrane  as  to  close  the  stump. 

Malig-nant  Connective-tissue  Tumors,  or  Sarcomata. — 
The  sarcomata  are  composed  of  embryonic  tissue.  They 
develop  from  connective  tissue,  have  no  definite  stroma, 
and  contain  no  lymphatics.  The  rapidly-growing  forms  are 
very  vascular,  the  blood  flowing  in  vessels  whose  walls  are 
very  thin  or  running  in  canals  whose  boundaries  are  sarcom- 
atous cells.  These  tumors  may  pulsate  and  have  a  bruit, 
and  hemorrhages  often  take  place  in  their  substance.  Slow- 
growing  sarcomata  have  but  few  vessels.  Sarcoma  dissem- 
inates by  means  of  the  blood  and  the  vessel-walls,  particles 
of  sarcoma  being  carried  by  the  venous  blood  to  the  heart  and 
from  this  organ  to  the  lungs,  where  they  lodge  and  form 
secondary  growths.  Emboli  from  this  secondary  focus  are 
sent  out  by  the  arterial  blood  to  various  portions  of  the 
body,  as  the  bones,  kidneys,  brain,  liver,  etc.  This  process 
is  known  as  "  metastasis."  Sarcoma  follows  the  vein-w^alls 
for  considerable  distances  and  builds  elongated  masses  inside 
the  veins.      Sarcoma   tends    strongly  to   infiltrate    adjacent 


TUMORS   OR   MORBID    GROWTHS.  211 

parts.  The  tumor  may  possess  a  capsule  when  it  is  in  an 
early  stage,  but  soon  loses  this  except  in  very  slow-growing 
or  mixed  forms  growing  by  central  proliferation.  Sarcomata 
may  arise  at  any  age  from  birth  to  extreme  senility,  but  they 
are  commonest  during  youth  and  early  middle  age.  They 
are  not  hereditary,  and  often  follow  contusion.  They  may 
arise  from  malignant  change  in  an  innocent  connective-tissue 
growth  (chondrosarcoma,  fibrosarcoma,  etc.).  A  sarcoma 
does  not  tend  to  affect  lymphatic  glands  except  by  the 
accident  of  its  position,  and  if  it  does  implicate  them,  the 
sarcomatous  elements  are  carried  rather  by  the  vein-walls 
and  blood  than  by  the  lymph  (melanotic  sarcoma  implicates 
adjacent  glands,  and  so  does  sarcoma  of  the  tonsil  or  of  the 
testicle).  The  skin  over  the  tumor  may  give  way,  a  bleeding 
fungus-mass  protruding  (fungus  hematoides),  and  suppura- 
tion may  cause  septic  enlargement  of  adjacent  glands. 
After  removal  of  a  sarcoma  the  growth  tends  to  recur,  and 
the  recurrent  tumor  may  be  either  more  or  less  malignant 
than  its  predecessor,  the  degree  of  malignancy  being  in 
direct  ratio  to  the  number  and  smallness  of  the  cells.  A 
sarcoma  is  malignant  by  local  tissue-infection  and  by  dis- 
semination. Sarcomata  rarely  cause  pain  when  they  are  not 
ulcerated.  Sarcomata  are  commonest  in  the  skin  and  con- 
nective tissue  of  the  extremities,  but  they  arise  also  from 
bone,  neuroglia,  periosteum,  in  the  lymphatic  glands,  the 
breast,  the  testicle,  the  eye,  the  parotid,  and  in  other  parts. 
Hemorrhages  into  a  sarcoma  often  occur,  with  the  result 
of  suddenly  increasing  its  size  and  forming  blood-cysts. 
Sarcomata  are  subject  to  partial  fatty  degeneration,  to 
myxomatous  changes  which  produce  cavities  filled  with 
fluid,  to  calcification,  and  occasionally  to  necrosis  of  large 
masses. 

Species  of  Sarcomata. — The  following  species  of  sarcomata 
are  recognized  : 


212  A    MANUAL    OF  SURGERY. 

1.  Round-celled,  in  which  the  matrix  is  soft  and  vascular. 
The  ceils  may  be  small  or  may  be  large.  The  smaller  the 
cell  the  more  malignant  the  growth.  A  small  round-celled 
sarcoma  is  the  most  malignant  variety  of  sarcoma  and  is  soft 
in  consistence. 

2.  Spindle-celled,  which  are  composed  of  bundles  of  spindle- 
cells  lying  in  a  matrix  which  may  be  homogeneous,  but  which 
may  show  some  attempt  at  fibre-formation.  Rhabdomyoma 
is  a  variety  of  spindle-celled  sarcoma  containing  striated 
muscle-cells.  These  spindle-celled  sarcomata  often  contain 
cartilage. 

3.  Mixed-celled  sarcoma,  containing  both  of  the  above 
varieties  of  cells. 

4.  Giant-celled  or  myeloid,  which  contains  some  round 
cells,  some  spindle-cells,  and  large  cells  with  many  nuclei, 
like  the  cells  of  bone-marrow.  It  is  maroon  colored  on 
section.  This  is  the  least  malignant  form  of  sarcoma,  and 
it  sometimes  admits  of  complete  extirpation  and  cure.  It 
tends  to  occur  in  the  long  bones  as  a  central  sarcoma. 

5.  Alveolar,  in  which  the  cells  are  collected  in  alveoli  as 
are  the  cells  of  cancer.     It  arises  usually  from  a  mole. 

6.  Melanotic,  which  may  be  composed  of  either  round 
cells  or  spindle-cells  containing  a  black  pigment. 

7.  Lympho-sarcoma,  which  is  composed  of  small  round 
cells  held  in  a  delicate  network,  the  tissue  somewhat  resem- 
bling that  of  a  lymphatic  gland. 

Cluneal  Varieties  of  Sarcojna. — The  following  are  the 
clinical  varieties  of  sarcoma : 

Melanotie  or  black  sarcoma,  the  color  of  which  is  due 
to  pigment  in  the  cells  or  matrix.  These  growths  are 
usually  round-celled,  but  may  be  spindle-celled ;  they  are 
sometimes  alveolar,  and  spring  from  parts  which  contain 
pigment  (skin  and  choroid  coat  of  the  eye) ;  they  are  apt 
to  arise  from  pigmented  moles  ;  they  are  very  malignant ; 


TUMORS   OR   MORBID    GROWTHS.  21 3 

they  implicate  related  lymphatic  glands,  and  during  their 
existence  the  urine  contains  pigment. 

Glio-sarconia  is  a  sarcoma  of  neuroglia.  A  pure  glioma  is 
composed  of  adult  connective  tissue;  but,  as  a  matter  of  fact, 
pure  glioma  almost  never  arises,  and  the  growth  practically 
always  contains  numerous  small  round  cells  and  is  properly 
a  sarcoma.  It  springs  from  the  neuroglia  of  the  central  ner- 
vous system,  and  is  usually  of  about  the  consistence  of  the 
cortex  of.  the  brain;  it  is  generally  single,  and  does  not 
cause  secondary  growths.  A  gliomatosis  of  the  cord  produces 
that  remarkable  disease  known  as  "  syringomyelia."  The 
symptoms  of  glioma  of  the  brain  depend  upon  its  situation. 

HeiuorrJiagic  sarcoma  is  a  sarcoma  containing  blood- 
cysts,  the  results  of  parenchymatous  hemorrhages. 

Cylindroma,  or  Plexiform  Sarcoma. — In  this  variety  the 
cells  adjacent  to  vessels  have  undergone  hyaline  degenera- 
tion ;  cells  distant  from  vessels  are  unchanged.  Section 
shows  the  normal  cells  apparently  contained  in  spaces  with 
hyaline  walls. 

Mixed  uimors  consist  partly  of  mature  and  partly  of 
embryonic  tissue,  the  cellular  elements  exceeding  the  adult 
elements  in  amount.  Among  these  mixed  tumors  are  fibro- 
sarcoma or  the  recurrent  fibroid  tumor,  myxo-sarcoma, 
chondro-sarcoma,  and  osteo-sarcoma. 

Treatment  of  Sarcomata. — Remove  a  sarcoma  at  once  if  it 
is  in  an  accessible  spot.  Never  delay  removal.  Cut  well 
clear  of  it.  The  rapidly-growing  soft  sarcomata  will  almost 
inevitably  return,  and  the  very  malignant  variety,  if  uninter- 
fered  with,  may  terminate  life  in  six  months ;  but  operation 
postpones  the  evil  day  and  renders  it  possible  that  death  will 
occur  from  metastasis  in  an  organ,  and  that  the  patient  will 
escape  the  horrors  of  ulceration  and  hemorrhage  from  the 
original  tumor.  Slowly-growing  and  hard  tumors  offer 
some  prospects  of  cure.     The  mixed  tumor  (as  a  recurrent 


214  A   MANUAL    OF  SURGERY. 

fibroid)  may  repeatedly  recur,  and  yet  the  patient  may  be 
cured  at  last  by  a  sixth,  an  eighth,  or  a  tenth  operation.  In 
sarcomata  of  the  long  bones  amputation  should,  as  a  rule,  be 
performed,  though  in  some  cases  of  giant-celled  sarcomata 
excision  can  be  employed.  In  sarcomata  of  the  jaw-bones, 
excision  ;  of  the  eye,  enucleation  ;  and  of  the  testicle,  castra- 
tion, are  demanded.  Sarcoma  of  the  ovary  in  adults  demands 
ovariotomy,  but  in  children  the  operation  is  useless.  Sar- 
coma of  the  kidney  in  adults  calls  for  nephrectomy,  but  in 
children  the  operation  is  of  no  avail.  In  melanotic  sarcoma 
remove  the  growth  and  adjacent  lymph-glands,  or  in  some 
cases  amputate.  Removal  of  a  sarcoma  when  there  is  no 
hope  of  a  cure  is  often  justifiable  to  prolong  life,  to  relieve 
the  patient  of  a  foul,  offensive,  bleeding  mass,  and  to  permit 
of  an  easier  road  to  death  by  means  of  metastasis  to  an 
internal  organ.  Wright  advocates  internal  treatment  for  sar- 
coma and  for  cancer.  He  advises  that  bromide  of  arsenic 
be  given  for  a  long  period  of  time,  the  dose  being  gr.  -^-^  to 
gr.  -^  after  each  meal.  Before  meals  gr.  x  of  carbonate  of 
lime  are  advised.  This  treatment,  Wright  holds,  should  be 
used  before,  and  for  many  months  after,  operation,  as  an  aid 
to  surgery.     In  inoperable  cases  it  may  be  tried. ^ 

It  has  been  observed  that  an  attack  of  erysipelas  occasion- 
ally greatly  benefits  a  sarcoma,  causing  large  masses  of  the 
growth  to  soften  or  to  slough  and  expose  a  granulating  sur- 
face. It  has  been  suggested  that  in  inoperable  cases  of 
sarcoma  this  condition  might  be  established  artificially.  A 
bouillon  culture  is  made  of  the  streptococci ;  this  culture 
is  filtered  through  porcelain  and  is  injected  once  a  day  into 
and  about  the  sarcoma.  The  first  dose  is  TTLx,  and  it  is 
increased  ;  it  should  cause  a  febrile  reaction,  and  sometimes 
establishes  softening  or  suppuration.  The  exact  status  of 
this  plan  is  not  determined ;  it  has  improved  or  possibly 
^  Annals  of  Surgery,  April,  1893. 


TUMORS   OR  MORBID    GROWTHS.  215 

cured  some  cases,  but  is  not  free  from  danger.^  The  injec- 
tion of  aniline  products  into  the  sarcoma,  which  has  received 
a  qualified  commendation  from  some  observers,  has  been 
abandoned  by  Profs.  Keen  and  White  after  careful  trial. 

Innocent  Epithelial  Tumors. — These  growths  imitate  an 
epithelial  tissue  of  the  mature  and  healthy  organism. 

Papillomata,  or  "Warts. — These  growths  are  formed  upon 
the  type  of  cutaneous  and  mucous  papillae.  A  papilloma 
consists  of  a  fibrous  stroma  which  contains  blood-vessels 
and  lymphatics  and  which  is  covered  by  epithelium  of  the 
variety  appertaining  to  the  diseased  part.  Warts  grow  from 
the  skin  and  from  mucous  membranes ;  they  may  be  single 
or  multiple;  they  may  be  painless  or  may  be  ulcerated  and 
bleeding ;  great  masses  may  gather  around  the  anus,  the 
vagina,  or  the  penis  during  the  existence  of  a  filthy  dis- 
charge, and  crops  appear  on  the  hands  of  those  who  work 
in  irritant  material  (as  petroleum).  A  large  crop  of  warts 
may  disappear  in  a  single  night ;  hence  the  popular  belief  in 
the  efficacy  of  charms.  A  single  wart  may  reach  a  large 
size  and  become  pigmented.  The  squamous  epithelium 
covering  a  skin-wart  may  become  horny  (a  wart- horn). 
Other  cutaneous  horns  arise  from  the  nails,  from  the  scars 
of  burns,  or  from  ruptured  sebaceous  cysts. 

Villous  papillomata  grow  chiefly  from  the  bladder ;  they 
form  tufts  like  the  villous  processes  of  the  chorion  ;  they  may 
be  single  or  multiple,  and  may  be  sessile  or  pedunculated  ; 
they  are  very  vascular,  and  are  apt  to  bleed  freely.  Papillo- 
mata may  arise  in  cysts  of  the  paroophoron,  in  cysts  of  the 
mammary  gland,  and  from  the  choroid  plexuses  of  the 
ventricles  of  the  brain.  A  villous  papilloma  of  the  choroid 
plexus  early  calcifies  and  becomes  converted  into  a  psam- 
moma.  Psammomata  of  the  spinal  membranes  may  arise. 
Any  papilloma  may  become  a  cancer. 

^  See  Coley,  in  American  Journal  of  Medical  Sciences  for  May,  1893. 


2l6  A   MANUAL    OF  SURGERY. 

Treatment. — Venereal  warts  are  treated  by  repeatedly 
washing  with  peroxide  of  hydrogen,  drying  with  cotton, 
and  dusting  with  a  powder  composed  of  equal  parts  of 
calomel  and  subnitrate  of  bismuth,  or  oxide  of  zinc  and 
iodoform,  or  borated  talcum.  If  they  do  not  soon  dry  up, 
cut  them  off  with  scissors  and  burn  with  the  Pacquelin 
cautery.  Ordinary  warts  may  usually  be  destroyed  in  a 
short  time  by  daily  applications  of  lactic  or  chromic  acid. 
Keeping  a  wart  constantly  moist  with  castor  oil  will  often 
cause  it  to  drop  off  Warts,  and  even  extensive  callosities, 
may  be  removed  by  painting  once  a  day  for  five  days  with 
pure  carbolic  acid  and  covering  with  lint  kept  wet  with 
boracic  acid.  A  convenient  plan  is  to  paint  a  wart  daily 
with  a  solution  containing  i  part  of  corrosive  sublimate  to 
30  parts  of  collodion  (hydrarg.  chlor.  corros.,  5ss  ;  collodion, 
3vij  et  ss).  Large  warts  should  be  freely  excised.  Villous 
papillomata  of  the  bladder  demand  the  performance  of  a 
suprapubic  cystotomy  in  order  to  remove  them.  Psammo- 
mata  cannot  be  diagnosticated  until  the  growth  is  exposed. 

Adenomata. — These  glandular  tumors  are  composed  of 
tissue  identical  with  that  of  normal  glands,  and  they  may 
contain  acini  and  ducts  like  racemose  glands  or  tubes  like 
tubular  glands.  They  grow  from  secreting  glands,  but  can- 
not produce  the  secretion  of  the  glands  from  which  they 
spring,  or,  if  they  do  secrete,  the  fluid  is  retained,  and  not 
discharged  by  the  gland-duct.  Adenomata  occur  in  the 
mammary  gland,  the  parotid,  the  ovary,  the  thyroid  gland, 
the  liver,  the  sweat-glands,  and  the  prostate,  and  as  pedun- 
culated growths  from  the  mucous  lining  of  the  intestine  and 
uterus.  They  are  encapsuled,  are  usually  single,  but  may  be 
multiple,  are  of  slow  growth,  but  may  attain  a  great  size; 
they  do  not  tend  to  recur  after  thorough  removal,  do  not 
involve  adjacent  glands,  and  do  not  disseminate ;  they  are 
firm  to  the  touch ;  they  tend  to  become  cystic  (especially  in 


TUMORS   OR   MORBID    GROWTHS.  21/ 

the  thyroid),  the  fluid  which  distends  the  ducts  being  due  to 
mucoid  hquefaction  of  the  proHferating  epithehum. 

In  the  breast  a  fibro-adenoma  has  a  distinct  capsule  ;  it  is 
elastic  and  movable,  is  usually  superficial,  and  one  occasion- 
ally exists  in  each  gland.  They  are  most  common  before 
the  age  of  thirty,  and  are  often  painful,  especially  during  men- 
struation. Cystic  adenomata  of  the  breast  attain  a  large  size  ; 
they  are  encapsuled  and  grow  slowly,  are  most  common 
after  the  thirtieth  year,  and  are  rarely  painful.  Both  fibro- 
adenoma and  cystic  adenoma  may  arise  in  the  male  breast. 
Young  unmarried  women  not  unusually  develop  in  the 
breast  small,  very  tender,  and  painful  bodies,  most  usually 
around  the  edge  of  the  areola,  which  bodies  increase  in  size 
and  become  more  tender  during  menstruation,  and  which  are 
only  cysts  of  the  mammary  tissue. 

Adenomata  of  the  thyroid  gland  begin  before  the  fifteenth 
year  (Gross).  Adenomata  may  arise  in  the  prostate  if  that 
gland  be  already  the  seat  of  senile  hypertrophy.  Adenoma 
of  mucous  glands  may  arise  in  the  young  or  the  middle- 
aged. 

Treatment. — Adenomata  require  extirpation.  B\'  confus- 
ing adenomata  of  the  mammary  gland  with  small  cysts  of 
that  structure  an  erroneous  belief  has  arisen  that  the  former, 
as  well  as  the  latter,  may  sometimes  be  cured  by  the  local 
use  of  iodine,  mercury,  and  ichthyol  and  the  internal  use  of 
iodide  of  potassium.  The  treatment  is  excision.  It  would 
be  as  easy  to  dissolve  off  a  rooster's  comb  by  iodide  of 
potassium  as  by  it  to  absorb  an  adenoma. 

Malig-nant  Epithelial  Tumors,  Carcinomata,  or  Cancers. 
— Cancers  are  tumors  growing  from  epithelial  surfaces,  and 
are  composed  of  epithelial  cells  which  are  clustered  in  spaces, 
nests,  or  alveoli  of  fibrous  tissue.  The  cells  of  a  cluster  are 
not  separated  by  any  stroma,  and  the  walls  of  the  alveoli 
carr^'  blood-vessels   and    lymphatics.     Cancers    are   always 


2l8  A   MANUAL    OF  SURGERY. 

derived  from  epithelium  (of  glands,  of  skin,  of  mucous  mem- 
brane, etc.),  and  if  found  in  a  non-epithelial  tissue  must  be 
secondary.  They  have  no  capsules,  rapidly  infiltrate  sur- 
rounding tissues,  are  firmly  anchored  and  immovable.  In  the 
besfinnine  a  cancer  is  a  local  lesion,  but  it  soon  attacks  related 
lymph-glands  and  by  means  of  the  lymph  is  disseminated 
throughout  the  system,  secondary  growths  arising  which  are 
identical  with  the  parent  growth.  Cancer  is  rare  before  the 
age  of  forty,  and  never  occurs  before  puberty;  seems  occa- 
sionally to  be  hereditary  ;  is  sometimes  linked  with  continued 
irritation  as  a  cause  (cancer  of  the  penis  in  phimosis ;  cancer 
of  the  lip  from  the  hot  stem  of  a  clay  pipe ;  chimney- 
sweeps' cancer  from  soot  in  the  scrotal  folds) ;  is  often  the 
seat  of  pricking  pain  ;  tends  strongly  to  recur  after  removal ; 
is  prone  to  ulcerate,  causing  pain,  hemorrhage,  and  cachexia ; 
makes  rapid  progress,  and  is  often  fatal  in  from  one  to  two 
and  a  half  years.  It  is  more  common  in  women  than  in 
men,  and  rarely  exists  with  tubercle.  After  a  cancer  has 
existed  for  a  time  in  an  important  structure,  or  after  a  super- 
ficial cancer  has  ulcerated  and  become  hemorrhagic,  there  is 
noted  in  the  individual  evidences  of  illness  and  exhaustion. 
We  speak  of  this  condition  as  the  "  cancerous  cachexia,"  and 
in  it  the  muscles  are  wasted,  the  body-weight  is  constantly 
diminishing,  the  complexion  is  sallow,  the  face  is  sunken, 
pearly  white  conjunctivae  contrast  strongly  with  the  yellow 
skin,  the  pulse  is  weak  and  rapid,  and  night-sweats  add  to 
the  exhaustion.  The  above  condition  is  due  to  pain,  loss 
of  sleep,  bleeding,  deprivation  of  exercise,  mal-assimilation 
of  food,  and  anxiety.  Cancer  may  kill  by  obstructing  a 
canal,  by  destroying  the  functions  of  a  viscus  or  organ,  by 
hemorrhage,  by  ansemia,  by  sepsis,  or  by  exhaustion. 

Classification  of  Carcinoinata. — Carcinomata  are  classified 
as  follows:  i.  Squamous-celled  cancer,  or  epithelioma; 
2.  Rodent  ulcer,  or  Jacob's  ulcer;  3.  Spheroidal-celled  cancer 


TUMORS   OR   MORBID    GROWTHS.  219 

(a,  scirrhus ;  b,  encephaloid ;  r,  colloid) ;  and  4.  Cylindrical- 
celled  cancer. 

Bpithelioniata. — An  epithelioma  may  arise  wherever  there 
is  pavement  epithelium,  and  it  is  especially  apt  to  appear  at 
the  junctions  of  skin  and  mucous  membrane  (as  the  lips)  or 
the  point  of  juxtaposition  of  different  kinds  of  epithelium. 
In  epithelioma  there  is  an  ingrowth  of  surface  epithelium 
into  the  sub-epithelial  connective  tissue,  colonies  of  cells 
growing,  inward  and  forming  epithelial  nests.  It  may  arise 
without  discoverable  cause,  it  may  follow  prolonged  irrita- 
tion, or  it  may  arise  in  a  wart  or  fissure.  In  the  nipple  it 
is  often  preceded  by  a  persistent  eczema,  due  probably  to 
psorosperms  and  known  as  Paget' s  disease.  Epithelioma 
generally  begins  as  a  warty  protuberance  which  soon  ulcer- 
ates. The  malignant  ulcer  has  a  hard,  irregular  base,  uneven 
edges,  a  foul,  fungus-like  bottom,  and  it  gives  off  a  sanious 
or  ichorous  discharge.  This  ulcer  is  the  seat  of  sharp  prick- 
ing pain,  sometimes  bleeds,  and  extends  over  a  considerable 
area,  embracing  and  destroying  all  structures.  Epithelioma 
affects  lymphatic  glands,  usually  early,  but  its  action  may  be 
delayed  for  eight  or  ten  months.  These  glands  break  down 
in  ulceration,  making  frightful  gaps  and  often  causing  fatal 
hemorrhage.  Dissemination  is  not  nearly  so  common  as  in 
other  forms  of  cancer,  but  it  does  sometimes  occur. 

A  rodent  or  JacoUs  ulcer  is  scarcely  ever  met  with  except 
upon  the  face,  it  being  especially  common  upon  the  nose  and 
forehead.  It  begins  after  the  age  of  forty  as  a  little  warty 
prominence  which  ulcerates  in  the  centre,  the  ulceration  pro- 
gressing at  a  rate  equal  to  the  new  growth,  and  sometimes 
healing  temporarily  at  one  spot  while  it  extends  at  another. 
Jacob's  ulcer  grows  slowly,  may  last  for  years,  does  not 
involve  the  lymphatics,  produces  no  constitutional  cachexia, 
and  is  rarely  fatal.  It  is  an  ulcer  with  irregular  edges  and  a 
smooth  base  of  a  grayish  color,  its  discharge  being  thin  and 


220  A   MANUAL    OF  SURGERY. 

acrid,  and  is  considered  to  be  a  malignant  epithelial  growth 
which  springs  from  a  sweat-gland,  a  sebaceous  gland,  or  a 
hair- follicle.  The  base  of  the  ulcer  is  hard,  which  differen- 
tiates it  from  lupus  (Hearn.)  From  lupus  the  bacilli  of 
tubercle  may  be  cultivated. 

Spheroidal-celled  Carcinomata. — [a)  Scirrhous  cancer  is 
a  white  and  fibrous  mass  which  has  no  capsule,  which  infil- 
trates tissues,  and  which  draws  in  toward  it,  by  the  contrac- 
tion of  its  outlying  processes,  adjacent  soft  parts,  thus 
producing  dimpling,  or,  as  in  the  breast,  retraction  of  the 
nipple.  It  is  composed  of  spheroidal  cells  in  alveoli  formed 
of  connective-tissue  bands.  The  commonest  seat  of  scirrhus 
is  the  female  breast.  It  occurs  also  in  the  skin,  vagina, 
rectum,  prostate,  uterus,  stomach,  and  oesophagus.  It  is 
most  frequent  in  women  after  forty.  It  begins  as  a  hard 
lump  which  is  at  first  painless,  but  soon  becomes  the  seat 
of  an  acute  localized  pricking  pain.  This  lump  grows  and 
becomes  irregular  and  adherent,  causing  puckering  of  the 
soft  parts.  After  the  skin  or  mucous  membrane  above  it 
has  become  infiltrated  ulceration  takes  place  and  a  fungous 
mass  protrudes  to  bleed  and  to  suppurate.  The  adjacent 
lymphatics  soon  become  involved,  and  the  constitutional 
involvement  is  rapid  and  certain. 

(h)  Encephaloid  cancer  is  a  soft  gray  or  brain-like  mass. 
It  is  a  rare  growth,  it  has  no  capsule,  and  it  may  appear 
in  the  kidney,  liver,  ovary,  testicle,  mammary  gland,  stom- 
ach, bladder,  and  antrum.  An  encephaloid  often  contains 
cavities  filled  with  blood,  and  this  variety  is  known  as  a 
"  hematoid  "  or  a  "  telangiectatic  "  carcinoma.  These  growths 
are  soft  and  semi-fluctuating,  they  infiltrate  rapidly  and  soon 
fungate,  and  they  terminate  life  in  from  a  year  to  a  year  and 
a  half  If  the  cells  of  encephaloid  become  filled  with  mel- 
anin, we  have  the  condition  known  as  *'  melanosis "  or 
"  melanotic  cancer." 


TUMORS   OR   MORBID    GROWTHS.  221 

(c)  Colloid  cancer  arises  from  either  a  scirrhus  or  an  en- 
cephaloid  cancer  when  the  cells  or  stroma  undergo  colloid 
degeneration.  On  section  we  see  in  the  centre  of  the  growth 
a  series  of  cavities  filled  with  a  material  resembling  honey 
or  jelly ;  the  periphery  often  shows  an  ordinary  scirrhus  or 
encephaloid  cancer.  Colloid  degeneration  is  most  prone  to 
attack  cancers  of  the  stomach,  mammary  gland,  and  intes- 
tine. 

Cylindrical-celled  carcinoniata  which  occur  in  the  rec- 
tum are  known  as  "adenoid  "  or  "glandular"  cancers.  They 
may  occur  in  this  region  at  a  much  earlier  age  than  do  can- 
cers elsewhere,  being  not  uncommon  between  the  ages  of 
twenty-eight  and  forty.  At  first  covered  by  mucous  mem- 
brane, they  soon  ulcerate  and  involve  the  submucous  and 
muscular  coats  in  the  growth.  They  grow  rather  slowly, 
and  take  usually  from  four  to  six  years  to  kill.  They  usu- 
ally, but  not  always,  cause  lymphatic  involvement  and  con- 
stitutional infection.  They  are  composed  of  a  stroma  of 
fibres  between  which  lie  tubular  glands  lined  with  columnar 
epithelium  and  masses  of  epithelial  cells. 

Treatment. — Carcinomata  demand  early  and  free  excision 
with  removal  of  implicated  glands.  A  certain  proportion 
can  be  cured.  Recurrent  growths  may  be  removed  as  a 
palliative  measure,  to  lessen  pain  and  to  relieve  the  patient 
from  ulceration  and  hemorrhage.  If  a  growth  does  not 
recur  within  five  years  after  removal,  a  cure  has  probably 
been  attained.  A  rodent  ulcer  should  be  excised  or  else  be 
curetted  and  cauterized  with  the  hot  iron  or  the  Pacquelin 
cautery.  In  cancer  of  the  lip,  remove  a  V-shaped  piece;  in 
cancer  of  the  tongue,  excise  this  organ  ;  in  cancer  of  the 
breast,  remove  the  breast  and  pectoral  fascia  and  take  away 
the  fat  and  glands  of  the  axilla ;  in  cancer  of  the  rectum,  if 
near  the  surface,  excise  the  rectum  from  below ;  if  above  five 
inches  from  the  anus,  do  the  sacral  resection  of  Kraske ;  in 


222  A    MANUAL    OF  SURGERY. 

cancer  of  the  ccsophagtis,  perform  gastrostomy ;  in  cancer  of 
the  pylorus^  perform  pylorectoniy  or  gastro-enterostomy ;  in 
cancer  of  the  bowel,  do  resection  with  anastomosis,  side-track 
the  diseased  area  by  an  anastomosis,  or  make  an  artificial 
anus ;  in  cancer  of  the  penis,  amputate. 

Cysts. — A  cyst  is  a  sac  containing  a  fluid  or  a  semi-fluid. 

Division  of  Cysts. — Cysts  are  divided  into  (\)  Retention-cysts, 
which  are  due  to  blocking  up  of  the  excretory  ducts  of 
glands  and  accumulation  of  the  glandular  secretions.  These 
comprise  sebaceous  cysts  or  wens,  serous  cysts,  mucous 
cysts,  salivary  cysts,  milk-cysts,  oil-cysts,  and  seminal  cysts. 
(2)  Exudation-cysts,  which  are  due  to  accumulations  in 
closed  cavities.  These  comprise  synovial  cysts  (ganglions 
and  bursae)  and  dentigerous  cysts.  (3)  Dermoid  cysts,  which 
are  congenital  and  arise  from  inversion  of  the  cutis  and  im- 
perfectly closed  foetal  clefts.  (4)  Cystomas,  which  are  cysts 
of  new  formation  due  to  cystic  degeneration  of  connective 
tissue.  These  cysts  are  found  in  the  neck  (hygroma),  in  the 
arm-pit,  and  in  the  perineum.  An  example  of  a  cystoma  is 
found  in  the  bursa  which  will  develop  from  pressure.  (5)  Ex- 
travasation-cysts, that  form  around  blood-extravasations.  (6) 
Hydatid  cysts,  or  cysts  due  to  the  echinococcus  or  tapeworm 
of  the  dog.  A  mother-cyst  is  formed,  which  becomes  filled 
with  daughter-cysts  floating  in  a  saline  liquor  containing 
hooklets. 

Sebaceous  cysts  arise  when  the  excretory  duct  of  a 
sebaceous  gland  is  blocked  by  dirt  or  occluded  by  inflam- 
mation. The  orifice  of  the  duct  is  often  visible  as  a  black 
speck  over  the  centre  of  the  cyst.  They  are  very  common 
in  the  scalp,  where  they  are  known  as  "  wens,"  and  upon  the 
face,  neck,  shoulders,  and  back.  Arising  in  the  skin,  and 
not  under  it,  the  skin  cannot  be  freely  moved  over  them, 
though  a  large  cyst  must  extend  into  the  deeper  tissues. 
A  sebaceous  cyst  is  lined  by  epithelium  and  is  filled  with 


TUMORS   OR   MORBID    GROWTHS.  223 

foul-smelling  sebaceous  material.  A  sebaceous  cyst  may 
suppurate. 

Treatment. — To  treat  a  sebaceous  cyst,  dissect  it  entirely 
away  with  scissors  or  an  Allis  dissector,  trying  not  to  rupture 
the  sac.  If  even  a  small  particle  of  it  is  left,  the  cyst  will 
return.  If  it  ruptures  during  removal  and  it  is  feared  that 
some  portion  may  remain,  swab  out  the  wound  with  pure 
carbolic  acid.  If  acid  is  not  used,  close  without  drainage, 
but  if  acid  is  used,  drain  for  twenty-four  hours.  If  an 
abscess  has  formed,  open  it.  Grasp  the  edges  of  the  cyst- 
lining  with  forceps,  dissect  out  this  lining  with  scissors 
curved  on  the  flat,  cauterize  with  pure  carbolic  acid,  and 
drain  for  twenty-four  hours. 

Dermoid  cysts  are  lined  with  true  skin.  They  contain 
sebaceous  matter,  hair,  teeth,  or  other  epiblastic  products. 
They  are  always  congenital,  but  may  be  so  small  at  birth  as 
to  escape  notice  for  years.  They  may  be  distinguished  from 
sebaceous  cysts  by  the  fact  that  they  always  lie  below  the 
deep  fascia,  and  hence  the  skin  is  freely  movable  over  them. 
They  are  met  with  at  the  root  of  the  nose,  at  the  orbital 
angles,  in  the  eyelids,  upon  the  floor  of  the  mouth,  over  the 
sacrum  or  coccyx,  and  in  the  ovaries,  the  testicles,  the  brain, 
the  eyes,  the  mediastinum,  the  lungs,  the  omentum,  the 
mesentery,  and  the  carotid  sheaths.  They  are  due  to  imper- 
fect closure  of  foetal  clefts  and  inclusion  of  epiblast.  If  a 
dermoid  cyst  contains  bones,  it  shows  that  mesoblast  was 
included  as  well  as  epiblast. 

Treatment. — To  treat  a  dermoid  cyst,  excise,  if  accessible, 
the  same  as  in  the  case  of  a  sebaceous  cyst.  If  it  lies  over 
bone,  go  down  to  the  bone  :  the  growth  will  be  found  ad- 
herent, so  remove  a  portion  of  periosteum  with  the  cyst 
(Hearn). 

Hydatid  cysts  occur  particularly  among  people  who  live 
shut  up  with  dogs,  as  is  the  case  in  Iceland.    The  parasite  is 


224  A   MANUAL    OF  SURGERY. 

swallowed  with  the  food  and  is  taken  up  by  the  stomach- 
veins,  and  penetrates  the  intestine  and  peritoneum  to  find  a 
nest  in  some  neighboring  or  distant  organ  or  tissue.  Open 
these  cysts,  scrape,  asepticize,  and  pack  with  iodoform  gauze. 

XVII.  DISEASES  AND  INJURIES  OF  THE  HEART 

AND  VESSELS. 

Heart  and  Pericardium. — In  an  acute  pulmonary  conges- 
tion the  venous  side  of  the  heart  is  over-distended  with 
blood,  and  the  surgeon  in  desperate  cases  may  tap  the  right 
auricle  (see  Paracentesis  aiuncidi).  Pericardial  effusion,  if 
severe,  calls  for  tapping  or  aspiration,  and  purulent  peri- 
carditis demands  incision  and  drainage. 

Wounds  and  Injuries. — The  heart  may  rupture  and  cause 
instant  death,  but  slight  wounds  may  not  prove  fatal.  A 
wound  of  the  heart  causes  hemorrhage,  usually  copious,  but, 
owing  to  the  interlocking  of  muscular  fibres,  the  hemorrhage 
is  often  slight.  If  bleeding  into  the  pericardal  sac  takes 
place,  the  signs  of  a  pericardial  effusion  become  manifest. 
Pain  is  constant,  and  attacks  of  syncope  are  the  rule.  Death 
is  apt  to  occur  suddenly  from  shock,  hemorrhage,  and 
inability  of  the  heart  to  contract  because  of  the  severed 
fibres,  or  inability  of  the  heart  to  dilate  because  of  the 
pressure  of  blood  in  the  pericardial  sac.  If  a  wound  of 
the  pericardium  or  heart  does  not  cause  death  in  the  first 
day  or  two,  inflammation  follows  (traumatic  pericarditis  or 
carditis). 

Treatment. — The  treatment  of  heart-wounds  consists  of 
recumbency  and  the  lowering  of  the  head.  The  body  is 
surrounded  with  hot  bottles,  opium  is  given  in  small  doses, 
and  stimulants  are  applied  in  moderation,  but  never  to  ex- 
cess. Traumatic  carditis  or  pericarditis  is  treated  in  the 
same  way  as  idiopathic  cases. 


DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS.     22 5 

Phlebitis,  or  Inflammation  of  a  Vein. — Phlebitis  may  be 
plastic  or  it  may  be  purulent.  Plastic  phlebitis,  while  occa- 
sionally due  to  gout,  to  a  febrile  malady,  or  to  some  other 
constitutional  condition,  usually  takes  its  origin  from  an 
injury,  from  the  extension  to  the  vein  of  a  perivascular 
inflammation,  or  from  a  thrombus  or  an  embolism.  When 
phlebitis  begins  a  thrombus  forms  because  of  the  destruction 
of  the  endothelial  coat,  and  this  clot  may  be  absorbed  or 
organized.  Suppurative  phlebitis  is  a  suppurative  inflamma- 
tion of  a  vein,  arising  by  infection  from  suppurating  peri- 
vascular tissues.  It  is  most  frequently  met  with  in  cellulitis 
or  phlegmonous  erysipelas,  and  may  arise  in  the  lateral  sinus 
as  a  result  of  mastoid  suppuration.  A  thrombus  forms,  the 
vein-wall  suppurates,  is  softened  and  in  part  destroyed,  and 
the  clot  becomes  purulent.  No  bleeding  occurs  when  the 
vein  ruptures,  as  a  barrier  of  clot  keeps  back  the  blood- 
stream. The  clot  of  suppurative  phlebitis  cannot  be  absorbed 
and  cannot  organize.  Septic  phlebitis  may  cause  pyaemia, 
and  the  infected  clots  of  pyaemia  may  cause  phlebitis. 

Symptoms. — The  symptoms  of  phlebitis  are  pain,  tender- 
ness in  and  around  a  vein,  discoloration  over  it,  and  solid 
oedema  below  the  seat  of  the  disease.  Suppurative  phlebitis 
causes  the  constitutional  symptoms  of  infection. 

Treatment. — The  treatment  of  phlebitis  comprises  rest  in 
bed,  elevation  of  the  part,  the  administration  of  tincture  of 
iron,  and,  locally,  lead-water  and  laudanum.  Hot  fomenta- 
tions are  used  later  in  the  case.  Abscesses  are  opened,  asep- 
ticized, and  drained.  Internal  treatment  is  symptomatic 
(opium,  stimulants,  etc.).  When  a  vein  is  involved  in  this 
process,  ligate,  if  possible,  above  and  below  the  clot,  open 
the  vessel,  and  wash  out  the  purulent  mass.  This  is  always 
to  be  done  in  infective  throm^bo-phlebitis  of  the  lateral  sinus. 

Varicose  Veins,  or  Varix. — Definition  and  Causes. — Vari- 
cose veins  are   unnaturally  and  permanently  dilated  veins 

15 


226  A   MANUAL    OF  SURGERY. 

which  elongate  and  pursue  a  tortuous  course.  The  causes 
of  varicose  veins  are  obstruction  to  venous  return  and  weak- 
ness of  cardiac  action,  which  lessens  the  propulsion  of  the 
blood-stream. 

Varicose  veins  are  chiefly  met  with  on  the  inner  side  of 
the  lower  extremity,  in  the  spermatic  cord,  and  in  the  rectum. 
Varix  in  the  leg  is  met  with  during  and  after  pregnancy  and 
in  persons  who  stand  upon  their  feet  for  long  periods.  It 
especially  appears  in  the  long  saphenous,  which,  being 
subcutaneous,  has  no  muscular  aid  in  supporting  the  blood- 
column  and  in  urging  it  on.  The  deep  as  well  as  the  super- 
ficial veins  may  become  varicose. 

Varix  of  the  spermatic  cord  is  known  as  "  varicocele." 
It  is  apt  to  appear  about  the  time  of  puberty,  and  most  adult 
men  have  at  least  a  slight  varicocele.  Varix  is  more  likely 
to  appear  in  the  left  spermatic  vein  than  in  the  vein  of  the 
right  side,  because  the  left  spermatic  vein  has  no  valves 
(Brinton). 

Varix  of  the  veins  of  the  rectum  is  known  as  "  hemor- 
rhoids "  or  "  piles,"  which  are  caused  by  obstruction  to  the 
upward  flow  in  the  hemorrhoidal  veins,  either  by  obstructive 
liver  disease,  enlargement  of  the  uterus  or  prostate,  or  the 
presence  in  the  rectum  of  fecal  masses  in  a  person  habitually 
constipated. 

A  vein  under  pressure  usually  dilates  more  at  one  spot  than 
at  another,  the  distention  being  greatest  back  of  a  valve  or 
near  the  mouth  of  a  tributary.  The  valves  become  incom- 
petent and  the  dilatation  becomes  still  greater.  The  vein- 
wall  may  become  fibrous,  but  usually  it  is  thin  and  often 
ruptures.  The  veins  not  only  dilate,  but  they  also  become 
longer,  and  hence  do  not  remain  straight,  but  twist  and  turn 
into  a  characteristic  form.  Varicose  veins  are  apt  to  cause 
oedema,  and  the  watery  elements  in  the  tissues  cause  eczema 
of  the  skin.     When  eczema  is  once  inaugurated,  excoriation 


DISEASES  AND  INJURIES   OF  HEART  AND    VESSELS.     22/ 

is  to  be  expected.  Infection  of  an  excoriated  area  produces 
inflammation,  suppuration,  and  an  ulcer. 

The  skin  over  varicose  veins  in  the  leg  is  often  discolored 
by  pigmentation  due  to  the  red  blood-cells  having  escaped 
from  the  vessel  and  broken  up.  The  tissues  around  a  vari- 
cose vein  become  atrophied  from  pressure,  and  there  is 
often  met  with  a  very  large  vein  whose  thin  walls  are  in 
close-  contact  with  skin.  In  this  condition  rupture  and 
hemorrhage  are  probable.  Varicose  veins  are  apt  to  inflame, 
and  thrombosis  frequently  occurs. 

Treatment. — The  treatment  of  varix  may  be  palliative  or 
curative.  In  palliative  treatment,  attend  to  the  general  health, 
keep  up  the  force  and  activity  of  the  circulation,  and  prevent 
constipation.  Recommend  the  patient  to  exercise  in  the  open 
air  and  to  lie  down,  if  possible,  every  afternoon.  Locally,  in 
varix  of  the  leg,  order  a  flannel  roller  or  a  Martin  rubber  band- 
age to  support  the  veins  and  drive  the  blood  into  the  deeper 
vessels  which  have  muscular  support.  Locally,  in  varicocele, 
pour  cold  water  upon  the  scrotum  twice  a  day  and  order  the 
patient  to  wear  a  suspensory  bandage.  Locally,  in  haemor- 
rhoids, use  astringent  suppositories.  The  curative  or  radical 
treatment  of  varix  of  the  leg  comprises  ligation  with  excision 
of  part  of  the  vein,  exposure  and  ligation  of  the  vein,  multiple 
subcutaneous  ligatures  of  catgut,  acupressure-pins  with  twisted 
sutures,  or  injection  of  pure  carbolic  acid  into  the  perivascular 
structures  (see  Operations  npon  Vessels). 

Nsevus. — (See  Tumors?) 

Arteritis,  or  inflammation  of  an  artery,  is  acute  or  is 
chronic. 

Acute  arteritis  may  result  from  injury  or  from  extension 
of  inflamm.ation  from  the  perivascular  tissues.  This  latter 
mode  of  origin  is  uncommon,  as  arteries  are  very  resistant  to 
the  spread  of  inflammation,  but  we  meet  with  it  sometimes 
in  suppurating  areas.     In  a  suppurating  acute  arteritis  the 


228  A   MANUAL    OF  SURGERY. 

coats  ulcerate  through,  but  hemorrhage  rarely  occurs  unless 
a  considerable  portion  of  the  vessel  sloughs.  Septic  emboli 
lodging  in  the  arterial  system  produce  acute  arteritis.  This 
is  seen  during  the  progress  of  ulcerative  endocarditis. 

Chronic  arteritis  produces  "  atheroma."  It  is  due  to  increase 
of  blood-pressure  from  hard  work,  strains,  heart  disease,  or 
contracted  kidney.  It  is  especially  common  in  drunkards 
and  in  the  lar";er  arteries.  It  is  commonest  in  the  acred, 
but  may  be  met  with  in  young  drunkards.  It  is  a  true 
saying  that  "A  man  is  as  old  as  his  arteries."  In  chronic 
arteritis  exudation  of  serum  and  leucocytes  takes  place 
beneath  the  intima,  which  coat,  in  consequence,  is  swelled 
out,  and  a  like  exudation  soon  becomes  manifest  in  the 
media,  in  the  adventitia,  and  even  in  the  sheath.  Embryonic 
tissue  is  formed,  which  may  undergo  resolution,  may  become 
fibrous  tissue  (arterial  sclerosis),  or  may  undergo  fatty  degen- 
eration (atheroma).  When  fatty  degeneration  occurs  the  en- 
dothelium is  destroyed,  the  vessel-wall  is  damaged,  and  the 
blood  obtains  access  to  the  deeper  coats.  Calcareous  change 
may  follow  fatty  degeneration. 

An  atheromatous  artery  is  rigid  and  inelastic,  and  the 
parts  it  supplies  are  cold,  congested,  and  ill-nourished. 
Atheroma  is  a  frequent  cause  of  thrombosis,  aneurysm,  senile 
gangrene,  and  apoplexy.  Syphilitic  arteritis  is  characterized 
by  an  enormous  growth  of  granulation  tissue  from  the  inner 
coats  (obliterative  arteritis)  of  arteries  of  small  size.  Calci- 
fication of  an  artery  may  be  secondary  to  fatty  change  or 
may  occur  primarily  from  deposit  of  lime  salts  in  the  middle 
coat.  Periarteritis  is  inflammation  of  the  sheath  and  outer 
coat.  An  acute  arteritis  is  always  local,  but  a  chronic 
arteritis  may  be  general. 

Treatment  of  acntc  arteritis  consists  of  rest,  elevation  and 
relaxation,  the  application  of  tincture  of  iodine,  and  the  use 
of  lead-water  and  laudanum.     Hot  fomentations  are  applied 


DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS.     229 

later.  Abscesses  are  opened  and  drained.  Internally,  treat 
any  diathesis  (rheumatic,  gouty,  or  syphilitic),  maintain 
kidney  secretion,  quiet  the  circulation,  and  employ  a  non- 
stimulating  diet.  The  part  must  be  kept  quiet,  as  rough 
movement  would  tend  to  rupture  the  vessel. 

Treatment  of  CJirojiic  Arteritis. — In  treating  chronic  arteritis, 
endeavor  to  antagonize  the  dangers  to  which  the  patient  is 
obviously  liable.  Stop  alcohol  as  a  beverage,  though  a  little 
whiskey  may  be  taken  at  meals  to  aid  digestion.  Maintain 
the  activity  of  the  skin  by  daily  baths,  and  of  the  kidneys 
by  diuretic  waters.  The  contents  of  the  bowels  are  to  be 
kept  soft.  The  diet  is  to  be  plain  and  is  to  contain  a  mini- 
mum of  nitrogen.  If  syphilis  has  existed,  occasional  courses 
of  iodide  are  to  be  urged.  If  the  arterial  tension  at  any  time 
becomes  inordinately  high,  give  nitroglycerin.  One  danger 
is  apoplexy  ;  hence  excitement  and  violent  exercise  are  to 
be  avoided.  Another  danger  is  senile  gangrene  ;  hence  the 
patient  should  wear  woollen  stockings,  put  a  hot  bottle  to 
his  feet  at  night,  and  be  careful  to  avoid  injuring  his  toes  or 
feet,  especially  when  cutting  his  corns.  When  a  patient  with 
atheroma  has  dyspnoea  and  is  of  a  livid  color,  or  when  the 
arterial  tension  is  very  high,  a  moderate  blood-letting  (six- 
teen to  eighteen  ounces)  does  good.  Still  another  danger 
is  aneurysm,  which  may  appear  suddenly  from  rupture  or 
gradually  from  progressive  distention. 

Aneurysm. — An  aneurysm  is  a  pulsating  sac  containing 
blood  and  communicating  with  the  cavity  of  an  artery. 
Some  restrict  the  term  "  true  aneurysm  "  to  a  condition  of 
dilatation  involving  all  the  coats  of  the  vessel.  We  shall 
consider,  with  Heath,  a  true  aneurysm  to  be  that  in  which 
the  blood  is  included  in  one  or  more  of  the  arterial  coats, 
and  a  false  aneurysm  to  be  that  in  which  the  vessel  has 
ruptured  or  has  atrophied  and  the  aneurysmal  wall  is  formed 
by  a  condensation  of  the  perivascular  tissues. 


230  A    MANUAL    OF  SURGERY. 

Forms  of  Aneurysm. — The  following  forms  of  aneurysm 
arc  recognized  : 

1.  True  mieiirysDi — one  whose  sac  is  formed  of  one  or 
more  arterial  coats. 

2.  False  aneurysm — one  whose  sac  is  formed  of  condensed 
perivascular  tissues  and  contains  no  arterial  coat. 

3.  Traumatic  aneurysm — a  false  aneurysm  due  to  traumatic 
rupture  some  time  before,  the  blood  being  in  a  sac  of  tissue 
and  all  wound  being  healed. 

4.  Fusiform  aneurysm — a  variety  of  true  aneur}'sm,  the 
sac  being  spindle-shaped. 

5.  Consecutive  aneurysm — a  sacculated  aneurysm  diffused 
by  rupture,  or  a  false  aneurysm  due  to  gradual  destruction 
or  atrophy  of  a  true  aneurysmal  sac  or  to  vascular  rup- 
ture. 

6.  Sacculated  aneurysm — a  common  form  of  aneurysm,  in 
which  the  dilatation  is  like  a  pouch,  arising  from  a  part  of 
the  arterial  circumference  and  joining  the  lumen  of  the  vessel 
by  an  aperture. 

7.  Dissecting  aneurysm — a  pouch-like  dilatation,  due  to  the 
blood  which,  passing  through  an  aperture  in  the  intima, 
enters  between  the  media  and  adventitia  and  dissects  them 
apart.  It  may  or  may  not  join  the  lumen  of  the  artery  at 
another  point  by  a  fresh  aperture  in  the  intima. 

8.  Arterio-venous  aneurysm,  which  is  divided  into  aneur}^s- 
mal  varix,  or  Pott's  aneurysm,  where  there  is  direct  commu- 
nication between  a  vein  and  an  artery,  and  varicose  aneurysm, 
where  there  is  communication  between  an  artery  and  a  vein 
by  means  of  an  interposed  sac. 

9.  Acute  aneurysm — a  cavity  in  the  walls  of  the  heart, 
which  cavity  communicates  with  the  interior  of  this  organ, 
and  which  is  due  to  suppuration  in  the  course  of  acute  endo- 
carditis or  myocarditis. 

10.  Aneurysm  by  anastomosis. — (See  Angeiomata}) 


DISEASES  AND  INJURIES   OF  HEART  AND    VESSELS.     23 1 

11.  Aneurysm  of  bone — a  clinical  term  to  designate  a 
pulsatile  tumor  of  bone. 

12.  Civeuniscribed  aneurysm — when  the  blood  is  circum- 
scribed by  distinct  walls. 

\^.  Cirsoid  a)ieurysm — a  mass  of  dilated  and  elongated 
arteries  shaped  like  varicose  veins  and  pulsating  with  each 
heart-beat. 

14.  Cylindrical  aneurysm — a  dilatation  of  the  same  dimen- 
sions for  a  considerable  space. 

15.  Embolic  or  capillary  aneurysm — dilatation  of  terminal 
arteries  due  to  emboli. 

16.  Spontaneous  aneurysm — non-traumatic  in  origin. 

17.  Miliary  aneurysm — a  minute  dilatation  of  an  arteriole. 

18.  Secondary  aneurysm — one  which,  after  apparent  cure, 
again  pulsates,  the  blood  entering  by  means  of  the  anasto- 
motic circulation. 

19.  Verminous  aneurysm — one  containing  a  parasite.  This 
form  of  aneurysm  is  met  with  in  the  mesenteric  artery  of  the 
horse. 

The  sac  of  a  sacculated  aneurysm  is  at  first  composed  of 
at  least  two  of  the  arterial  coats,  reinforced  by  the  sheath 
and  perivascular  tissues.  After  a  time  the  blood-pressure 
distends  the  sac,  and  the  inner  and  middle  coats  either  stretch 
with  interstitial  growth  or — what  is  more  common — are  worn 
away  and  lost.  When  all  the  coats  are  lost,  and  the  blood 
is  sustained  only  by  the  sheath  and  surrounding  tissue,  a 
true  aneurysm  becomes  a  diffused  or  consecutive  aneurysm, 
the  limiting  tissues  and  sheath  being  condensed,  thickened, 
and  glued  together.  This  limiting  process  is  deficient  in 
the  brain ;  hence  cerebral  aneur}'sms  break  soon  after  their 
formation.  When  all  the  arterial  coats  are  lost,  the  blood- 
pressure,  acting  on  the  tissues,  finds  some  spots  less  resistant 
than  others,  the  blood  follows  the  lines  of  least  resistance, 
the  aneurysm  grows  with  great  rapidity,  and  soon  ruptures. 


232  A   MANUAL    OF  SURGERY. 

An  aneurysm  may  rupture  into  a  cavity  (pleura,  pericar- 
dium, or  peritoneum),  into  the  perivascular  tissues,  or 
through  the  skin.  Rupture  into  the  tissues  may  produce 
pressure-gangrene.  When  rupture  occurs  through  the  skin, 
the  hemorrhage  is  not  often  instantly  fatal,  but  is  during 
days  constantly  recurrent  in  larger  and  larger  amounts. 
The  pressure  of  an  aneurysmal  sac  causes  atrophy  of 
tissues,  hard  and  soft,  bones  and  cartilages  being  as  easily 
destroyed  as  muscles  and  fat.  Sometimes  the  perivascular 
tissues  inflame  and  suppurate,  and  the  sac  is  opened  rapidly 
by  sloughing.  An  aneurysm  usually  progresses  toward 
rupture,  the  slowest  in  this  progression  being  the  fusiform 
dilatations,  which  may  exist  for  many  years,  but  which 
finally  eventuate  in  the  sacculated  variety. 

In  some  rare  instances  there  takes  place  spontaneous  cure, 
which  may  result  from  laminated  fibrin  being  deposited  upon 
the  walls  of  the  sac  as  the  blood  circulates  through  it.  This 
laminated  fibrin  is  known  as  an  '*  active  clot,"  and  eventually 
fills  the  sac.  The  weaker  and  slower  the  blood-stream,  the 
greater  is  the  tendency  to  the  formation  of  an  active  clot ; 
hence  any  agent  impeding,  but  not  abolishing,  the  circula- 
tion aids  in  the  deposition.  This  weakening  and  slow- 
ing of  circulation  may  be  brought  about  by  great  activity 
of  the  collateral  circulation  deviating  most  of  the  blood 
away  from  the  area  of  disease.  Sometimes  a  clot  breaks 
off  from  the  sac-wall  and  plugs  the  artery  beyond  the 
dilatation,  and  the  anastomotic  vessels,  enlarging,  divert  the 
blood-stream.  A  large  aneurysm,  falling  over  by  its  own 
weight  upon  the  vessel  above  the  mouth  of  the  sac,  may 
diminish  the  blood-stream.  The  development  of  another 
aneurysm  upon  the  same  vessel  weakens  the  circulation  in 
the  older  one.  Inflammation  occasionally  forms  a  clot. 
The  tissues  about  an  aneurysm  tend  to  contract  when 
arterial  force  is  lessened ;   hence  tissue-pressure  may  more 


DISEASES  AND   INJURIES   OF  HEART  AND    VESSEIS.     233 

than  counteract  blood-pressure  when  the  circulation  is  feeble. 
Clotting  of  the  blood  contained  within  a  sac,  circulation 
through  the  aneurysm  having  ceased,  causes  a  passive  clot. 
A  passive  clot,  which  occasionally  cures,  may  arise  from  a 
twisting  of  the  neck  of  the  sac,  preventing  the  passage  of 
blood ;  from  the  lodgment  of  a  clot  in  the  mouth  of  the 
sac ;  and  from  inflammation.  Spontaneous  cure  is,  unfortu- 
nately, very  rare. 

Causes  of  Aneurysin. — Gradual  distention  of  arterial  coats 
which  are  in  a  condition  of  arterial  sclerosis,  or  local  loss 
of  resisting  power  due  to  atheroma,  may  cause  aneurysm. 
Hence  the  causes  of  sclerosis  and  atheroma  are  also  causes 
of  aneurysm.  The  principal  cause  of  aneurysm  is  increased 
blood-pressure.  This  increase  may  be  brought  about  by 
severe  labor;  by  sudden  strains,  as  in  lifting;  by  violent 
efforts,  as  in  rowing  in  a  boat-race ;  by  chronic  interstitial 
nephritis ;  by  hypertrophy  of  the  heart ;  by  alcoholic  in- 
ebriety ;  and  by  syphilis.  Arterial  disease  is  commonest 
in  the  larger  vessels  and  in  the  aged,  but  it  may  occur  in 
youth.  When  an  aneurysm  follows  a  strain,  it  may  be  due 
to  laceration  of  the  media  and  loss  of  resistance  at  a  narrow 
point.  The  intima  may  lacerate,  permitting  the  blood  to 
come  in  contact  with  the  media  or  causing  it  to  diffuse 
between  the  coats  (dissecting  aneurysm).  An  embolus  may 
cause  an  aneurysm  on  its  proximal  side.  The  embolus,  if  in- 
fective, causes  softening,  and  if  calcareous  causes  laceration 
(Osier).  Colonies  of  micrococci  may  cause  aneurysm.^  The 
parasite  sirongylus  annatiis  causes  aneurysm  of  the  mesenteric 
arteries  in  horses.  Suppuration  around  a  vessel  weakens 
its  coats  and  tends  to  aneurysm  by  inducing  acute  arteritis 
and  softening.  Some  people  develop  many  aneurysms  the 
origins  of  which  are  lost  in  mystery. 

TJie  constituent  parts  of  an  aneurysm  are  (r)  the  wall  of 

^  See  Osier  on  Malionant  Endocarditis. 


234  A    MANUAL    OF  SURGERY. 

the  sac ;  (2)  the  cavity ;  (3)  the  mouth ;  and  (4)  the  con- 
tents. 

Symptoms  of  Aneurysm. — A  pulsatile  tumor  exists,  which 
instantly  ceases  to  pulsate  and  almost  or  entirely  disappears 
on  making  firm  pressure  on  the  artery  above.  On  relaxing  the 
pressure  the  pulsatile  enlargement  at  once  reappears.  Direct 
pressure  upon  the  tumor  causes  it  to  almost  or  entirely  disap- 
pear. Pressure  upon  the  artery  below  causes  the  tumor  to  en- 
large. The  pulsation  is  expansile — that  is,  it  expands  in  all 
directions — and  if  an  index  finger  be  laid  on  each  side  of  the 
tumor  so  that  their  points  nearly  touch,  each  pulsation  not 
only  lifts  the  fingers,  but  it  also  separates  them.  On  placing 
a  stethoscope  over  the  aneurysm  there  is  imparted  to  the 
ear  a  distinct  bruit  which  travels  in  the  direction  of  the 
blood-stream  and  is  systolic  in  time.  In  internal  aneurysms 
pressure-symptoms  are  marked.  Thoracic  aneurysm  causes 
intercostal  pain;  iliac  aneurysm  causes  pain  in  the  thigh. 
Aneurysm  of  the  aorta  presses  upon  the  pneumogastric  nerve, 
causing  spasmodic  dyspnoea,  and  upon  the  recurrent  laryn- 
geal, causing  loss  of  voice  and  paralysis  of  all  the  muscles 
of  the  larynx  except  the  crico-thyroid.  The  pulse  below  an 
aneurysm  is  weaker  than  the  pulse  of  a  corresponding  part 
of  the  opposite  limb.  This  is  well  shown  by  the  sphygmo- 
graph,  the  tracings  being  rounded  without  a  sudden  rise  or 
an  abrupt  fall  (PI.  i,  Figs.  5,  6). 

Diagnosis. — A  cyst  or  abscess  over  a  vessel  may  show 
transmitted  pulsation  which  is  not  expansile,  and  the  tumor 
does  not  disappear  on  pressure  above  it.  There  is  no  true 
bruit,  and  the  history  is  widely  different.  A  growth  under 
a  vessel  may  lift  the  vessel  and  simulate  an  aneurysm,  but 
the  pulsation  is  not  noted  in  the  entire  growth,  the  growth 
does  not  disappear  on  proximal  pressure,  and  there  is  only 
a  false,  and  never  a  true,  bruit.  The  larger  the  growth  the 
less  is  the  pulsation  due  to  pressure  upon  the  vessel.     A 


DISEASES  AND  INJURIES   OF  HEART  AND    VESSELS.     235 

sarcoma,  especially  a  soft  sarcoma  attached  to  the  bone, 
pulsates  and  often  has  a  bruit ;  it  never  disappears  from 
proximal  pressure,  though  it  may  slowly  diminish  in  size,  to 
gradually  enlarge  again  when  pressure  is  withdrawn.  An 
aneurysm  may  cease  to  pulsate  from  consolidation  leading 
to  cure,  or  from  rupture.  Rupture  of  a  large  aneur\-sm  into 
a  cavnty  induces  deadly  pallor,  syncope,  and  rapid  death. 
Rupture  of  an  aneurysm  of  an  extremity  into  the  tissues  is 
made  manifest  by  a  sensation  of  something  breaking,  by 
pain,  by  sudden  increase  in  size,  by  absence  of  bruit  and 
pulsation,  by  absence  of  pulse  below  the  aneurysm,  by 
swelling  and  coldness  of  the  limb,  and  by  shock. 

Treatment. — In  inoperable  ^inQurysms  general,  medical,  and 
dietetic  treatment  must  be  tried.  It  consists  chiefly  in  rest 
in  bed  to  diminish  the  rapidity  and  force  of  the  circulation 
and  favor  fibrinous  deposit.  Tufnell's  plan  is  to  reduce  the 
heart-beats  by  rest  and  mental  quiet,  and  to  rigidly  restrict 
the  diet  so  as  to  diminish  the  total  amount  of  blood  and 
render  it  more  fibrinous.  Liquids  are  restricted  in  amount, 
and  the  patient  lives  for  twenty-four  hours  upon  four  ounces 
of  bread,  a  very  little  butter,  eight  ounces  of  milk,  and  three 
ounces  of  meat.  Pursue  this  plan  for  several  months  if  pos- 
sible, or  employ  it  for  several  weeks  at  a  time  over  and  over 
again.  There  can  be  no  doubt  that  Tufnell's  treatment 
sometimes  cures  by  decidedly  lowering  the  blood-pressure. 
Valsalva  long  ago  suggested  rest,  occasional  bleeding,  and 
a  diet  just  above  the  point  of  starvation.  In  many  cases  of 
aneurysm  the  patient  may  be  permitted  to  go  about,  taking 
his  time  about  everything  and  avoiding  work,  worr\%  and 
excitement.  The  diet  is  low  and  non-stimulating,  and  the 
bowels  must  be  maintained  in  a  loose  condition. 

Iodide  of  potassium  in  doses  of  20  grains  undoubtedly 
does  good,  and  not  only  in  syphilitic  cases.  It  seems  to 
lower  the  blood-pressure.     Balfour  taught  that  it  thickened 


236  A   MANUAL    OF  SURGERY. 

the  sac.  Osier  says  it  relieves  the  pain.  Iron,  acetate  of 
lead,  and  ergotine  are  prescribed  by  some.  Digitalis  is 
contraindicated,  as  it  raises  the  blood-pressure.  Morphia 
and  bromide  of  potassium  are  occasionally  useful  to  tran- 
quillize the  circulation,  allay  pain,  or  secure  sleep.  Aconite 
and  veratrum  viride  have  long  been  employed.  Other  expe- 
dients are :  the  kneading  of  the  sac  to  release  a  clot,  in  the 
hope  that  it  will  plug  the  mouth  of  the  sac  or  the  artery 
beyond  it — this  is  dangerous  ;  electricity  ;  electrolysis ;  the 
injection  of  an  astringent  liquid ;  the  insertion  of  a  fine 
aspirating-needle  and  the  pushing  through  it  into  the  sac  of 
a  large  quantity  of  silver  wire,  in  the  hope  that  it  will  aid  in 
whipping  out  fibrin.  Some  physicians  have  inserted  needles 
and  horse-hair. 

Even  in  an  operable  case  diet  and  rest  are  of  importance. 
The  patient  should  be  in  bed  for  a  number  of  days  before 
operation,  the  daily  diet  consisting  of  ten  or  twelve  ounces 
of  solid  food  with  a  pint  of  milk.  If  the  circulation  is  very 
active,  use  aconite  and  allay  pain  by  morphia. 

Treatment  by  Pressure. — Instrumental  pressure  is  made  by 
applying  two  Signorini  tourniquets  or  some  specially-devised 
apparatus  to  limit  the  flow  of  blood  through  an  aneurysm 
without  entirely  stopping  it,  the  aneurysmal  sac  being  felt 
to  still  slightly  pulsate.  These  instruments  can  be  worn  for 
from  twelve  to  sixteen  hours  at  a  time,  usually  removing 
them  to  permit  sleep  and  reapplying  them  the  next  day,  and 
so  on  for  several  days.  This  method  may  cure,  but  it  is 
very  painful.     It  aids  in  the  formation  of  an  active  clot. 

Digital  pressure,  made  with  the  thumb  aided  by  a  weight, 
and  maintained  for  many  hours  by  a  relay  of  assistants,  has 
cured  many  cases.  It  entirely  cuts  off  the  blood  and  pro- 
motes the  formation  of  a  passive  clot. 

Direct  pressure  upon  the  sac  has  been  used  in  aneurysm 
of  the  popliteal  artery,  the  pressure  being  obtained  by  flexing 


DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS.     237 

the  leg;  and  in  aneurysm  of  the  brachial  artery  pressure  has 
been  obtained  at  the  bend  of  the  elbow  by  flexing  the  elbow. 
The  pressure  of  a  hollow  rubber  ball  has  been  used  in  aneur- 
ysm of  the  subclavian. 

Rapid  pressure  completely  arrests  the  passage  of  blood 
through  the  sac  for  a  limited  time,  and  is  applied  while  the 
patient  is  under  the  influence  of  an  anaesthetic.  Take,  for 
example,  a  case  of  popliteal  aneurysm  :  the  patient  is  placed 
under  ether;  two  Esmarch  bandages  are  used,  one  being  put 
on  the  limb  from  the  toes  to  the  lower  limit  of  the  aneurysm, 
and  the  other  from  the  groin  down  to  the  upper  limit  of  the 
sac,  and  the  Esmarch  band  is  fastened  above  the  upper 
bandage.  This  procedure  stagnates  the  blood  both  in  the 
veins  and  in  the  arteries,  the  sac  remaining  full  of  blood. 
Pressure  is  thus  maintained  for  three  or  four  hours,  and  on 
removing  the  Esmarch  apparatus  a  tourniquet  is  put  on  the 
artery  above  the  aneurysm  and  partly  tightened  to  limit 
the  amount  of  blood  passing  through  and  thus  prevent 
the  washing  away  of  clot.  This  method  of  rapid  pressure 
sometimes  cures  by  forming  a  passive  clot,  but  it  sometimes 
results  in  gangrene. 

Operative  Treatment :  By  the  Ligature. — Ligation  of  the 
main  artery  is,  as  a  rule,  the  best  procedure.  The  methods  of 
ligation  are — (i)  the  method  of  Antyllus  ;  (2)  the  method  of 
Anel ;  (3)  the  method  of  Hunter;  (4)  the  method  of  War- 
drop  ;   and  (5)  the  method  of  Brasdor. 

In  the  method  of  Antyllus  the  sac  itself  is  attacked. 
Hemorrhage  is  controlled  by  the  Esmarch  bandage,  the  sac 
is  opened,  its  contents  turned  out,  and  the  artery  ligated 
immediately  above  and  below  the  sac.  This  method  is  onh' 
employed  for  traumatic  aneurysms,  as  its  use  in  aneurysms 
from  diseased  vessel-walls  would  mean  that  the  ligatures 
were  almost  surely  applied  upon  diseased  areas   (Fig.  31). 

The  Method  of  Anel. — In   Anel's   method    the  artery  is 


238 


A   MANUAL    OF  SURGERY. 


ligated  close  to  and  above  the  sac  (Fig.  32).  It  is  only  used 
for  traumatic  aneurysms,  and  is  never  employed  when  the 
vessel  is  diseased. 

The  Method  of  Hunter — This    operation,    which    is   the 
modern  method  of  ligation,  was  devised  by  the  illustrious 


(I 


D 


Fig.  31. — Old  Operation  of  Antyllus  for 
Aneurysm  {Atn.  Text-Book  of  Surgery). 


Fig.  32. — Anel's   Operation   for   Aneurysm 
{Am.  Text-  Book  of  Su rg e ry ) . 


John  Hunter.  He  recognized  the  fact  that  the  vessel  adjacent 
to  an  aneurysm  was  apt  to  be  diseased,  and  he  discovered 
the  anastomotic  circulation.  Putting  together  these  two  facts, 
he  devised  the  operation  which  goes  by  his  name.  It  con- 
sists in  applying  a  ligature  between  the  heart  and  the 
aneurysm,  but  so  far  above  the  sac  that  collateral  branches 
are  given  off  between  it  and  the  point  of  ligation  (Fig.  33). 
This  operation,  which  is  done  upon  a  healthy  area,  does  not 


Fig.  33. — Hunter's  Operation  for  Aneurysm  {American  Text-Book  of  Surgery). 

at  once  cut  off  all  blood,  but  so  diminishes  the  force  and 
frequency  of  the  circulation  that  an  active  clot  forms  within 
the  sac.  Thus  is  lessened  the  danger  of  secondary  hemor- 
rhage and  of  gangrene.  It  is,  as  a  rule,  the  proper  opera- 
tion for  aneurysm.  In  some  cases  pulsation  does  not  return 
after  tightening  the  ligature ;  in  most  cases,  however,  it 
reappears  for  a  time  after  about  thirty -six  hours,  but  is  weak 
and  constantly  diminishing.     Previous  prolonged  compres- 


DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS.     239 

sion  by  enlarging  the  collateral  branches  permits  strong 
pulsation  to  soon  recur  after  ligation,  and  thus  militates 
against  cure ;  hence  it  is  a  bad  plan  to  use  pressure  in  cases 
where   its  success  is  very  uncertain. 

Distal  Ligation. — When  an  aneurysm  is  so  near  the  trunk 
that  Hunter's  operation  is  impracticable,  or  when  the  artery 
on  the  cardiac  side  of  the  tumor  is  greatly  diseased,  distal 
ligation  can  be  employed.  Distal  ligation  forms  a  barrier 
to  the  onflow  of  blood,  collateral  branches  above  the  aneur- 
ysm enlarge,  the  blood-current  is  gradually  diverted,  and 
a  clot  is  formed.  Distal  ligation  is  used  in  some  aneurysms 
of  the  aorta,  iliacs,  innominate,  carotids,  and  subclavians. 


=s^ 


Fig.  34. — Brasdor's  Operation  (Holmes).  Fig.  35. — Wardrop's  Operation  (Holmes). 

The  operation  of  Brasdor  consists  in  tying  the  main  trunk 
some  little  distance  below  the  aneurysm  (Fig.  34). 

TJie  operation  of  Wardrop  consists  in  tying  one  of  the 
branches  of  the  artery  below  the  aneurysm  (Fig.  35). 

After  ligating  for  aneurysm  by  any  of  these  methods, 
elevate  the  limb;  keep  it  warm,  and  subdue  arterial  excite- 
ment. When  moist  gangrene  follows  ligation,  amputate 
early,  above  the  ligature.  When  dry  gangrene  takes  place, 
await  a  line  of  demarcation.     Rupture  of  the  sac  after  liga- 


240  A   MANUAL    Of  SURGERY. 

tion  may  produce  gangrene  or  suppuration,  the  first  condition 
demanding  amputation,  and  the  second  incision  for  drainage. 

Ampiitatioii  for  aiicurysm  is  performed  in  some  perilous 
cases  of  subclavian  aneurysm  instead  of  distal  ligation. 

Electrolysis. — An  attempt  may  be  made  to  coagulate  the 
blood  at  once,  or  from  time  to  time  an  endeavor  may  be  made 
to  produce  fibrinous  deposits,  but  the  first  method  is  the 
better.  It  is,  however,  rarely  possible  to  at  once  occlude 
a  sac,  and  pulsation,  which  is  for  a  time  abolished,  recurs 
as  the  gas  present  is  absorbed.  Use  the  constant  current. 
Take  from  three  to  six  cells  which  stand  in  point  of  size 
between  those  used  for  cautery  and  those  used  for  ordinary 
medical  purposes.  A  platinum  needle  is  attached  to  the 
positive  pole  and  a  steel  needle  to  the  negative  pole,  both 
needles  being  insulated  by  vulcanite  at  the  points  where  the 
skin  will  touch  them.  The  asepticized  needles  are  plunged 
into  the  sac  where  it  is  thick  and  they  are  kept  near  together. 
The  current  is  passed  for  a  variable  period  (from  half  an  hour 
to  an  hour  and  a  half).  This  operation  is  not  dangerous. 
Pressure  stops  the  bleeding.  Electrolysis  sometimes  cures, 
and  often  ameliorates,  aortic  aneurysms.^ 

Acupressure  consists  of  the  partial  introduction  of  a  num- 
ber of  ordinary  sewing-needles  into  an  aneurysmal  sac  and 
leaving  them  in  it  for  five  or  six  days  or  more. 

Introduction  of  Wire. — Insert  into  the  sac  a  hypodermatic 
or  small  aspirating-needle,  and  push  through  the  needle  or 
canula  a  considerable  quantity  of  aseptic  silver  wire,  which 
is  allowed  to  remain  permanently.  Loreta  combines  elec- 
trolysis with  the  introduction  of  wire. 

Traumatic  aneurysm  is  a  condition  in  which,  after  punc- 
ture or  rupture  of  an  artery,  a  sac  has  formed  of  tissue,  and 
if  any  wound  previously  existed,  it  has  healed.  The  treat- 
ment consists  in  ligation  by  the  method  of  Antyllus.    When 

*  See  John  Duncan,  in  Heath's  Dictionary. 


DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS.     241 


an  artery  ruptures  and  a  large  mass  of  blood  is  extravasated, 
no  sac  exists,  and  it  is  an  error  to  designate  this  condition 
as  a  diffuse  traumatic  aneurysm.  There  is  no  pulsation  in 
the  tumor  nor  in  the  arteries  below  it,  and  the  limb  is  cold 
and  swollen.  If  the  main  vein  is  also  ruptured,  or  if  the 
rupture  has  occurred  into  a  large  joint,  amputate;  otherwise 
perform  the  operation  of  Antyllus. 

Arterio-venous  aneurysm  is  an  unnatural  passage-way 
between  a  v^ein  and  an  artery,  through  which  passage  blood 
circulates.  There  are  two  forms :  {a)  ajicurysnial  varix, 
where  a  vein  and  an  artery  directly  communicate ;  and 
(/;)  varicose  aneurysm,  where  vein  and  artery  communicate 
through  an  intervening  sac.  These  conditions  arise  usually 
from  punctured  wounds,  the  instrument  passing  through  one 
vessel  and  into  the  other,  blood  flowing  into  the  vein,  the 


Fig.  36. — Plan  of  an  Aneurj'smal  Varix  Fig.  37. — Varicose  Aneurysm  (Spence). 

{A/Jierican  Text-Book  0/  Surgery). 

subsequent  inflammation  gluing  the  two  vessels  together, 
and  the  aperture  faiHng  to  close  (aneurysmal  varix,  Fig.  36). 
After  the  infliction  of  the  wound  the  two  vessels  may  sepa- 
rate, the  blood  still  flows  from  artery  into  vein,  and  the 
blood-pressure,  by  consolidating  tissue,  forms  a  sac  of 
junction  (varicose  aneurysm,  Fig.  37).  Aneurysmal  varix 
is  a  far  less  grave  disorder  than  varicose  aneurysm. 

Symptoms. — In  aneurysmal  varix  a  swelling  exists  with 
the  characteristic  pulsation  and  a  loud  whirring  bruit  is 
transmitted  along  the  veins.  The  veins  above  and  below 
the  tumor  are  enlarged,  tortuous,  and  pulsating.  A  distinct 
thrill  is  felt.     Pressure  over  the  tumor  stops  the  thrill  and 

16 


242  A   MANUAL    OF  SURGERY. 

greatly  lessens  the  bruit.  The  extremity  is  apt  to  be  swollen 
and  the  parts  are  usually  painful.  When  pressure  on  the 
main  artery  causes  the  entire  disappearance  of  the  tumor, 
the  case  is  one  of  aneurysmal  varix ;  but  if  on  applying  this 
pressure  the  veins  collapse  and  a  distinct  tumor  remains 
which  can  be  emptied  by  direct  pressure,  the  case  is  one  of 
varicose  aneurysm.  If  light  pressure  on  one  spot  stops  both 
murmur  and  thrill,  it  is  aneurysmal  varix.  The  diagnosis 
between  the  two  is  often  impossible. 

Treatment. — Aneurysmal  varix  often  requires  only  palli- 
ative measures,  as  it  does  not  tend  to  rupture,  the  veins 
becoming  thick  and  resistant  and  after  a  time  ceasing  to 
enlarge.  Some  form  of  support  is  used.  If  the  part  is 
painful  or  the  veins  promise  rupture,  tie  the  artery  above 
and  below  the  opening.  Varicose  aneurysm  requires  the  use 
of  the  plans  ordinarily  adopted  in  treating  aneurysm  (com- 
pression, etc.).  If  these  fail,  tie  the  artery  above  and  below 
the  opening,  but  do  not  open  the  sac. 

Cirsoid  aneurysm,  or  aneurysm  by  anastomosis,  con- 
sists in  great  dilatation  with  pouching  and  lengthening  of 
one  or  several  arteries.  The  disease  progresses  and  after 
a  time  involves  the  veins  and  capillaries.  The  walls  of 
the  arteries  thin  and  the  vessels  tend  to  rupture.  Cirsoid 
aneurysm  is  met  with  upon  the  forehead  and  scalp  of 
young  people,  where  it  sometimes  takes  origin  from  a 
naevus. 

Symptoms. — A  pulsating  mass,  irregular  in  outline,  com- 
posed of  dilated,  elongated,  and  tortuous  vessels  that  empty 
into  one  another.  The  mass  is  soft,  can  be  much  reduced  by 
direct  pressure,  and  is  diminished  by  compression  of  the  main 
artery  of  supply.  A  thrill  and  a  bruit  exist.  Pregnancy 
and  puberty  cause  a  rapid  growth  of  a  cirsoid  aneurysm. 

Treatment. — In  treating  a  cirsoid  aneurysm  the  ligation 
of  the  larger  arteries  of  supply  is  a  wretched  failure.     Sub- 


DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS.     243 

cutaneous  ligation  at  many  points  of  the  diseased  area  has 
effected  a  cure  in  some  cases,  but  it  has  failed  in  most. 
Direct  pressure  is  also  entirely  useless.  Ligature  in  mass 
has  been  successful.  Destruction  by  caustic  has  its  advo- 
cates. Electro-puncture  with  circular  compression  of  the 
arteries  of  supply  has  once  or  twice  effected  a  cure.  Injec- 
tion of  astringents  has  been  recommended.  Verneuil  ligated 
the  afferent  arteries,  incised  the  tissues  around  the  tumor, 
and  sunk  a  constricting  ligature  into  the  cut.  The  proper 
method  of  treatment  is  excision  after  the  subcutaneous  liga- 
tion of  every  accessible  tributary  of  supply.^ 

Wounds  of  arteries  are  divided  into  contused,  incised, 
lacerated,  punctured,  and  gunshot  wounds,  and  vascular 
ruptures. 

Contused  and  Incised  Wounds. — A  contusion  may  destroy 
vitality  and  be  followed  by  sloughing  and  hemorrhage.  A 
contused  wound  may  do  little  damage,  or  it  may  produce 
gangrene  from  thrombus,  or  it  may  cause  secondary  hemor- 
rhage. In  an  incised  wound  there  is  profuse  hemorrhage. 
The  artery  after  a  time  is  apt  to  contract  and  retract,  and 
thus  arrest  bleeding.  A  transverse  wound  causes  profuse 
bleeding,  but  there  is  a  better  chance  for  natural  arrest  than 
in  an  oblique  or  in  a  longitudinal  wound.  In  a  partially- 
divided  artery,  cut  it  entirely  through  and  tie  both  ends. 
The  clot  which  forms  in  a  cut  artery  is  known  as  the  "  in- 
ternal clot ;"  it  reaches  as  high  as  the  first  collateral  branch, 
and  subsequently  becomes  organized  permanently,  obliter- 
ates the  vessel,  and  converts  it  into  a  shrunken  fibrous  cord. 
Between  the  vessel  and  its  sheath,  over  the  end  of  the  vessel, 
and  in  the  surrounding  perivascular  tissues  is  the  '*  external 
clot." 

Lacerated  zvounds  cause  little  primary  hemorrhage.  The 
internal   coat  curls   up,  the  circular  muscular  fibres  of  the 

^Anderson,  in  Heath's  Diclionary. 


244  ^   MANUAL    OF  SURGERY. 

media  contract  upon  it,  and  the  external  coat  is  so  pulled 
out  as  to  cap  the  orifice  of  the  vessel — all  of  which  con- 
ditions favor  clotting.  The  vessel-wall  is  so  damaged  that 
secondary  hemorrhage  is  usual. 

Punctured  Wounds. — In  punctured  wounds  primary  hem- 
orrhage is  slight.  Secondary  hemorrhage  is  not  usual.  Dif- 
fuse aneurysm  and  arterio-venous  aneurysm  are  not  unusual 
results. 

Gunshot  wounds  are  apt  to  be  contusions  which  may 
eventuate  in  sloughing  and  secondary  hemorrhage  or  throm- 
bosis and  gangrene.  A  shell -fragment  makes  a  lacerated 
wound.  A  rifle-bullet  may  make  a  clean-cut  division  of  an 
artery.  Secondary  hemorrhage  after  gunshot  wounds  tends 
to  occur  during  the  third  week.  Partial  rupture  of  an  artery 
may  cause  sloughing  and  secondary  hemorrhage,  thrombosis 
and  gangrene,  and  aneurysm.  Complete  rupture  is  a  lacer- 
ated wound,  and  is  a  condition  accompanied  by  diffuse  trau- 
matic aneurysm. 

Wounds  of  veins  are  classified  as  are  wounds  of  arteries. 
The  symptom  of  any  vascular  wound  is  hemorrhage. 

I.   Hemorrhage,  or  Loss  of  Blood. 

Hemorrhag-e  may  arise  from  wounds  of  arteries,  veins,  or 
capillaries,  or  from  wounds  of  the  three  combined.  In  arte- 
rial hemorrhage  the  blood  is  scarlet  and  appears  in  jets  from 
the  proximal  end  of  the  vessel,  which  jets  are  synchronous 
with  the  pulse-beats;  the  stream,  however,  never  intermits. 
The  stream  from  the  distal  end  is  darker  and  is  not  pulsa- 
tile. Venous  hemorrhage  is  denoted  by  the  dark  hue  of 
the  blood  and  by  the  continuous  stream.  In  capillary  hem- 
orrhage red  blood  wells  up  like  water  from  a  sponge. 

In  subcutaneous  hemorrhage  from  vascular  rupture  (dif- 
fuse aneurysm)  there  are  great  swelling,  cutaneous  discolora- 
tion, and  systemic  signs  of  hemorrhage.     If  an  artery  rup- 


DISEASES  AXD   INJURIES   OF  HEART  AND    VESSELS.    245 

tures  in  an  extremity,  there  is  no  pulse  below  the  rupture.  If 
a  vein  ruptures  in  an  extremity,  intense  oedema  occurs.  Pro- 
fuse hemorrhage  induces  constitutional  symptoms,  and  death 
may  occur  in  a  few  seconds.  Generally,  after  the  bleeding 
has  gone  on  for  a  time  syncope  occurs,  which  is  Nature's 
effort  to  arrest  hemorrhage,  for  during  this  state  the  feeble 
circulation  and  the  increased  coagulability  of  the  blood  give 
time  for  the  formation  of  a  clot.  When  reaction  occurs  the 
clot  may  hold,  or  it  may  be  washed  away  with  a  renewal  of 
bleeding  and  syncope.  These  episodes  may  be  repeated 
until  death  supervenes.  Nausea  and  vertigo  exist,  black 
specks  float  before  the  eyes  (muscae  volitantes),  tinnitus 
aurium  exists,  delirium  is  not  unusual,  and  convulsions 
often  occur.  After  a  profuse  hemorrhage  an  individual  is 
intensely  pale  and  of  a  sort  of  greenish  tinge ;  the  eyes  are 
fixed  in  a  glassy  stare  and  the  pupils  are  widely  dilated  ;  the 
respirations  are  shallow  and  sighing;  the  skin  is  covered 
with  a  cold  sweat ;  the  legs  and  arms  are  extremely  cold ; 
the  pulse  is  soft,  small,  compressible,  fluttering,  or  often 
cannot  be  detected ;  the  heart  is  very  weak  and  fluttering  ; 
and  there  is  musular  tremor.  When  such  a  dangerous  con- 
dition is  due  to  a  visible  hemorrhage,  temporarily  arrest 
bleeding  by  digital  pressure  in  the  wound,  lower  the  head, 
and  have  compression  made  upon  the  femorals  and  sub- 
clavians,  so  as  to  divert  more  blood  to  the  brain.  Apply 
artificial  heat.  Inject  by  hypodermoclysis  the  normal  salt 
solution  (10  to  16  ounces)  into  the  cellular  tissue  of  the 
buttock ;  inject  ether  hypodermatically,  then  brandy,  and 
then  strychnia  in  doses  of  gr.  2^.  Atropia,  digitalis,  and 
morphia  are  recommended.  Give  enemata  of  hot  coffee 
and  brandy.  Apply  mustard  over  the  heart  and  spine.  As 
soon  as  reaction  begins,  arrest  the  bleeding  permanently  by 
the  ligature. 

Hemorrhagic  Fever. — A  profuse  bleeding  is  apt  to  be  fol- 


246  A   MANUAL    OF  SURGERY. 

lowed  by  fever — hemorrhagic  fever — due  to  the  absorption 
of  fibrin  ferment  from  extravasated  blood  and  its  action  upon 
a  profoundly  debilitated  system.  In  this  form  of  fever  there 
are  most  intense  thirst,  violent  headache,  dimness  of  vision, 
great  restlessness,  often  mental  wandering,  with  a  very  fre- 
quent, weak,  and  fluttering  heart. 

Treatment. — In  treating  a  patient  after  a  severe  hemor- 
rhage, apply  cold  to  the  head  to  prevent  serous  effusion  into 
the  brain.  Aconite,  morphia,  and  neutral  mixture  are  given 
by  the  mouth.  Fluids  and  ice  are  grateful.  Frequently 
sponge  the  skin  with  alcohol  and  water  (S.  W.  Gross). 
Milk  punch,  koumiss,  and  beef-peptonoids  are  given  at 
frequent  intervals.  If  the  hemorrhage  is  from  some  spot  inac- 
cessible to  ligation,  such  as  the  lung,  give  the  patient  3  grains 
of  gallic  acid,  i  grain  of  powdered  digitalis,  i  grain  of  ergotine, 
and  ^  grain  of  powdered  opium  every  three  or  four  hours. 

Hemostatic  ag"ents  comprise  (i)  the  ligature ;  (2)  torsion  ; 
(3)  acupressure;  (4)  compression;  (5)  styptics  ;  (6)  the  actual 
cautery ;  and  (7)  forced  flexion  of  limbs. 

The  ligature  may  be  made  of  silk,  floss-silk,  or  catgut,  but 
it  must  be  aseptic.  The  ligatures  should  be  about  ten  inches 
long.  The  vessel  is  drawn  out  with  forceps  and  separated 
from  surrounding  tissues.  The  forceps  are  better  than  the 
tenaculum  in  most  cases,  because  the  tenaculum  makes  a 
hole  through  which  blood  may  subsequently  exude.  When 
the  artery  lies  in  hard  tissues  or  is  retracted  deeply  in  muscle 
or  fascia,  the  tenaculum  is  best.  Tie  with  a  reef-knot.  The 
tightening  of  the  first  knot  cuts  the  internal  and  middle 
coats  ;  the  second  knot  must  not  be  tied  too  tightly,  or  it 
will  cut  the  ligature.  Do  not  jerk  the  ligature  in  tying, 
and  cut  it  off  close.  Both  ends  of  the  vessel  are  tied. 
If  an  artery  is  incompletely  divided,  tie  on  each  side  of 
the  cut  and  entirely  sever  the  vessel  between  the  liga- 
tures.    If  a   large  vein   is   slightly  torn,    try   pinching   up 


DISEASES  AXD   hXJURIES    OF  HEART  AXD    VESSELS     247 

the  vein-walls  around  the  rent  and  apply  a  ligature  (lateral 
ligature).  If  the  bleeding  comes  from  an  artery  very  close 
to  its  point  of  origin,  tie  the  main  trunk  as  well  as  the  bleed- 
ing branch,  otherwise  the  clot  formed  will  be  too  short  and 
secondary  hemorrhage  will  be  inevitable.  When  the  parts 
about  an  artery  are  so  thickened  that  the  artery  cannot  be 
drawn  out,  arm  a  Hagedorn   needle  (Fig.  38)  with  catgut 

and  so  pass  the  latter  around  the 
vessel  that  the  catgut  will  include 


Fig.  38. — Hagedorn  Needles.  Fig.  39. — Torsion  in  Continuity  (Bernard  and  Huette). 

the  vessel  with  some  of  the  surrounding  tissue,  and  tie  the 
ligature.  This  method  is  pursued  in  necrosis,  atheroma, 
scar-tissue,  sloughing,  etc.  Never  include  a  nerve.  If  this 
mode  of  ligation  fails,  try  acupressure. 

Toj'sion. — By  means  of  torsion  the  internal  and  middle 
coats  are  ruptured  and  the  external  coat  is  twisted.  It  is  a 
safe  procedure,  and  is  practised  by  many  surgeons  of  high 
standing  upon  vessels  as  large  as  the  femoral.  Torsion  has 
the  signal  merit  of  not  introducing  possible  infection  in  liga- 
tures. The  vessel  is  drawn  out  by  one  pair  of  forceps,  and 
another  pair  is  applied  transversely  half  an  inch  above  the 
cut  end  and  twisted  six  or  eight  times.  Figure  39  a,  b 
shows  torsion  in  continuity. 


248  A   MANUAL    OF  SURGERY. 

Acupressw'c  is  pressure  with  a  pin.  A  pin  is  simply  passed 
under  a  vessel  (transfixion),  leaving  a  little  tissue  on  each 
side  between  the  pin  and  vessel.  A  needle  can  be  passed 
under  a  vessel,  and  a  wire  be  thrown  over  the  needle  and 
twisted  (circumclusion).  The  needle  can  be  inserted  upon 
one  side,  passed  through  half  an  inch  of  tissues  up  to  the 
vessel,  be  given  a  quarter-twist,  and  be  driven  into  the  tissues 
across  the  artery  (torsoclusion).  Some  tissue  is  picked  up 
on  the  needle,  folded  over  the  vessel,  and  pinned  to  the  other 
side  (retroclusion).  Acupressure  is  used  for  inflamed  or 
atheromatous  vessels,  in  sloughing  wounds,  and  where  a 
ligature  will  not  hold. 

Compression  is  either  direct  or  indirect — that  is,  in  the 
wound  or  upon  its  artery  of  supply.  In  the  removal  of  the 
upper  jaw,  arrest  bleeding  by  plugging.  In  injury  of  a  cere- 
bral sinus,  plug  with  gauze.  Compression  and  hot  water 
(120°)  will  stop  capillary  bleeding.  A  graduated  compress 
is  often  used  in  hemorrhage  from  the  palmar  arch.  A  com- 
press will  arrest  bleeding  from  superficial  veins.  The  knotted 
bandage  of  the  scalp  will  arrest  bleeding  from  the  temporal 
artery.  Long-continued  pressure  causes  pain  and  inflam- 
mation. 

Styptics. — Chemicals  are  now  rarely  used.  In  epistaxis 
we  may  pack  with  plugs  of  gauze  saturated  in  antipyrine. 
In  bleeding  from  a  tooth-socket,  pack  with  styptic  cotton 
(absorbent  cotton  soaked  in  Monsel's  solution  and  dried). 
In  bleeding  from  an  incised  urinary  meatus,  pack  with 
styptic  cotton.  Cold  water  or  ice  acts  as  a  st}^ptic  by  pro- 
ducing reflex  vascular  contraction.  Hot  water  produces 
contraction  and  coagulates  the  albumen.  The  temperature 
should  be  from  115°  to  120°  F.  A  mixture  of  equal  parts 
of  alcohol  and  water  stops  capillary  oozing. 

The  actual  cautery  is  a  most  ancient  hemostatic.  It  is 
still    used  in  some   cases    after  excising  the  upper  jaw,  in 


DISEASES  AND  INJURIES   OE  HEART  AND    VESSEIS.     249 

bleeding  after  the  removal  of  some  malignant  growths,  in 
continued  hemorrhage  from  the  prostatic  plexus  of  veins, 
after, lateral  lithotomy,  and  to  stop  oozing  after  the  excision 
of  venereal  warts.  We  are  driven  to  it  in  "  bleeders  " — that 
is,  those  persons  who  have  a  hemorrhagic  diathesis,  and  who 
may  die  from  having  a  tooth  pulled  or  from  receiving  a 
scratch.  It  will  arrest  hemorrhage,  but  sloughing  is  bound 
to  occur,  and  when  the  slough  separates  secondary  hemor- 
rhage is  apt  to  set  in.  The  iron  for  hemostatic  purposes 
must  be  at  a  black  heat. 

Forced  flexion  is  a  variety  of  indirect  compression.  It 
will  stop  bleeding,  but  soon  becomes  intensely  painful. 

Golden  Rules  for  Procedure  in  Primary  Hemorrhage. — 
I.  In  arterial  hemorrhage,  tie  the  artery  in  the  wound, 
enlarging  the  wound  if  necessary.  In  tying  the  main  artery 
of  the  limb  in  continuitx-  we  fail  to  cut  off  the  bleedinsj-  from 
the  distal  extremity,  and  hemorrhage  is  bound  to  recur.  If 
we  fail  to  look  into  the  wound,  we  cannot  know  what  is  cut : 
it  may  be  only  a  branch,  and  not  a  main  trunk.  Tlie  same 
rule  obtains  in  secondary  hemorrhage  (Guthrie's  rule). 

2.  Ligate  veins  as  we  would  arteries. 

3.  In  a  wound  of  the  superficial  palmar  arch,  tie  both  ends 
of  the  divided  vessel. 

4.  In  a  w^ound  of  the  deep  palmar  arch,  enlarge  the 
wound,  if  necessary,  in  the  direction  of  the  flexor  tendons,  at 
the  same  time  maintaining  pressure  upon  the  brachial  artery. 
Catch  the  ends  of  the  arch  with  hemostatic  forceps  and  tie 
both  ends.  If  the  artery  can  be  caught  by,  but  cannot  be 
tied  over  the  point  of,  the  forceps,  leave  the  instrument  on 
for  four  days.  If  the  artery  cannot  be  caught  with  forceps, 
try  a  tenaculum.  If  these  means  fail,  insert  a  small  piece  of 
gauze  in  the  depth  of  the  wound,  put  over  this  a  larger  piece, 
and  keep  on  adding  bit  after  bit,  each  one  larger  than  its 
predecessor,  until  there    is    constructed  a  conical    pad  the 


250  A   MANUAL    OF  SURGERY. 

apex  of  which  is  against  the  extremities  of  the  cut  arch  and 
the  base  of  which  is  well  external  to  the  palm.  Bandage 
each  finger  and  the  thumb,  put  a  piece  of  metal  over  the 
pad,  put  a  compress  in  front  of  the  elbow,  flex  the  forearm 
upon  the  arm,  wrap  the  hand  in  gauze,  place  the  arm  upon 
a  straight  splint,  apply  firmly  an  ascending  spiral  reverse 
bandage  of  the  arm,  starting  as  a  figure-of-8  of  the  wrist, 
and  hang  the  hand  in  a  sling.  The  pad  is  left  in  place  for 
six  or  seven  days  unless  bleeding  keeps  on  or  recurs.  If 
bleeding  is  maintained  or  begins  again,  ligate  the  radial 
and  ulnar.  If  this  manoeuvre  fails,  we  know  that  the 
interosseous  artery  is  furnishing  the  blood  and  that  the 
brachial  must  be  tied  at  the  bend  of  the  elbow.  If  this 
fails,  amputate  the  hand. 

5.  In  primary  hemorrhage,  if  the  bleeding  ceases,  do  not 
disturb  the  parts  to  look  for  the  vessel.  If  the  vessel  is 
clearly  seen  in  the  wound,  tie  it ;  otherwise  do  not,  as  the 
bleeding  may  not  recur.  This  rule  does  not  hold  good  when 
a  large  artery  is  probably  cut,  when  the  subject  will  require 
transportation  (as  on  the  battle-field),  when  a  man  has 
delirium  tremens,  mania,  or  delirium,  or  when  he  is  a  heavy 
drinker.     In  these  cases  always  look  for  an  artery  and  tie  it. 

6.  When  a  person  is  bleeding  to  death,  arrest  hemorrhage 
temporarily  by  digital  pressure  in  the  wound  and  apply 
above  the  wound  a  tourniquet  or  Esmarch  bandage.  Bring 
about  reaction  and  then  ligate,  but  do  not  operate  during 
collapse  if  the  bleeding  can  be  controlled  by  pressure. 

7.  If  an  artery  be  divided  incompletely,  put  a  ligature  on 
each  side  of  the  vessel-wound  and  then  sever  the  artery  so 
as  to  permit  of  complete  retraction. 

8.  If  a  branch  comes  off  just  below  the  ligature,  tie  the 
branch  as  well  as  the  main  trunk. 

9.  If  a  branch  of  an  artery  is  divided  very  close  to  a  main 
trunk,  tie   the   branch  and  also   the    main   trunk.     If  the 


DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS.     25  I 

branch  alone  be  tied,  the  internal  clot,  being  very  short,  will 
be  washed  away  by  the  blood-current  of  the  larger  vessel. 

10.  If  a  large  vein  is  slightly  torn,  put  a  lateral  ligature 
upon  its  wall.  Gather  the  rent  and  the  tissue  around  it  in  a 
forceps  and  tie  the  pursed-up  mass  of  vein-w^all. 

11.  When  a  branch  of  a  large  vein  is  torn  close  to  the 
main  trunk,  tie  the  branch,  and  not  the  main  trunk.  Apply 
practically  a  lateral  ligature. 

12.  If,  after  tying  the  cardial  extremity  of  a  cut  artery,  the 
distal  extremity  cannot  be  found  even  by  a  careful  search 
after  enlarging  the  wound,  firmly  pack  the  wound. 

13.  In  bleeding  from  diploe  or  cancellous  bone,  use 
Horsley's  antiseptic  wax. 

14.  In  bleeding  from  a  vessel  in  a  bony  canal,  plug  the 
canal  with  an  antiseptic  stick  and  break  the  wood,  or  fill  up 
the  orifice  of  the  canal  with  antiseptic  wax ;  or,  if  this  fails, 
ligate  the  artery  of  supply. 

15.  In  bleeding  from  the  internal  mammary  artery,  pass  a 
large  curved  needle  holding  a  piece  of  silk  into  the  chest, 
under  the  vessel  and  out  again,  and  tie  the  thread  tightly. 

16.  In  bleeding  from  an  intercostal  artery,  make  pressure 
upward  and  outward,  or  throw  a  ligature  by  means  of  a 
curved  needle  entirely  over  a  rib,  tying  it  externally,  or 
resect  a  rib  and  tie  the  artery. 

17.  In  collapse  due  to  puncture  of  a  deep  vessel,  the  bleed- 
ing having  ceased,  do  not  hurry  reaction  by  stimulants.  Give 
the  clot  a  chance  to  hold.  Wrap  the  sufferer  in  hot  blankets. 
If  the  condition  is  dangerous,  however,  stimulate  to  save  life. 

18.  In  punctured  wounds,  as  a  rule,  try  pressure  before 


usmsf  lio-ation. 


19.  After  a  severe  hemorrhage  always  put  the  patient  to 
bed  and  elevate  the  damaged  part  (if  it  be  an  extremity  or 
the  head). 

20.  A  clot  which  holds  for  twelve  hours  after  a  primary 


252  A   MANUAL    OF  SURGE]y!Y. 

hemorrhage  will  probably  hold  permanently ;  but  even  after 
twelve  hours  be  watchful  and  insist  on  rest. 

21.  If  recurrence  of  a  hemorrhage  from  a  limb  is  feared, 
mark  with  aniline  or  iodine  the  spot  on  the  main  artery  where 
compression  is  to  be  applied,  put  on  a  tourniquet  loosely,  and 
order  the  nurse  to  screw  it  up  and  to  send  for  the  physician 
at  the  first  sign  of  renewed  bleeding.  This  must  often  be 
done  in  gunshot  wounds. 

22.  In  extra-dural  hemorrhage,  trephine.  The  side  to  be 
trephined  is  determined  by  the  symptoms,  and  not  by  the  situ- 
ation of  the  injury.  The  opening  is  made  on  a  level  with  the 
upper  orbital  border  and  one  and  a  quarter  inches  behind  the 
external  angular  process.  This  opening  exposes  the  middle 
meningeal  and  its  anterior  branch  (Keen).  If  this  does  not 
expose  a  clot,  trephine  over  the  posterior  branch,  on  the  same 
level  and  just  below  the  parietal  eminence.  When  the  clot 
is  found,  enlarge  the  opening  with  the  rongeur,  scoop  out 
the  clot,  and  stop  the  bleeding  by  passing  a  catgut  ligature 
through  the  dura,  under  the  "artery  and  out  again,  and  then 
tying  it. 

23.  In  hemorrhage  from  a  cerebral  sinus,  catch  the  edges 
of  the  opening  with  forceps  if  possible  and  ligate  ;  apply  a 
lateral  ligature,  or  leave  the  forceps  on  for  forty-eight  hours, 
or  compress  firmly  with  one  large  piece  of  iodoform  gauze. 

24.  In  extra-medullary  spinal  hemorrhage  rapidly  advanc- 
ing and  threatening  life,  perform  a  laminectomy  and  arrest 
the  hemorrhage. 

25.  In  bleeding  from  a  tooth-socket,  use  ice.  If  this  treat- 
ment fails,  plug  with  gauze  infiltrated  with  tannin,  close  the 
jaws  upon  the  plug,  and  hold  them  with  Barton's  bandage. 
If  this  expedient  fails,  soak  the  plug  in  Monsel's  solution, 
and  if  this  is  futile,  use  the  cautery.  Pressure  on  the  carotid 
and  ice  over  the  jaw  and  neck  are  indicated.  It  may  be 
necessary  to  tie  the  common  carotid. 


DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS.     253 

26.  In  intra-abdominal  hemorrhage,  open  the  belly.  If 
the  blood  accumulates  so  rapidly  as  to  prevent  the  location 
of  the. bleeding  point,  compress  the  aorta  or  pack  the  abdomi- 
nal cavity  with  large  sponges.  •  In  parenchymatous  hemor- 
rhage, try  packing  with  iodoform  gauze.  In  the  liver,  if  this 
fails,  suture  the  torn  edge  or  use  the  cautery.  Severe  wounds 
of  the  spleen  demand  splenectomy ;  those  of  the  kidney, 
nephrectomy.  Mesenteric  vessels  are  ligated  en  masse  with 
silk  (Senn).  Wounds  of  stomach  and  intestines  causing 
hemorrhage  require  stitching  of  their  edges.  When  there 
are  an  infinite  number  of  points  of  bleeding,  take  a  number 
of  sponges,  tie  a  piece  of  iodoform  gauze  firmly  to  each  one, 
pack  many  places  in  the  belly  with  the  sponges,  bring  the 
gauze  out  of  the  wound,  and  remove  the  sponges  from  below 
upward  one  at  a  time,  securing  the  bleeding  points  as  they 
come  into  view. 

27.  In  abdominal  section  for  disease  of  the  female  pelvic 
organs,  bleeding  is  limited  b}'  the  clamp  or  by  pressure-for- 
ceps. Ligation  en  masse  is  often  practised.  Use  silk.  A 
large  mass  can  be  transfixed  and  tied  in  sections.  Bleeding 
edees  are  stitched.  Areas  of  oozin^  are  treated  with  tem- 
porary  pressure  and  hot  water,  or,  if  this  fails,  by  the  cautery. 
Packing  can  be  used  as  a  tamponade,  which  is  a  gauze  pouch, 
pieces  of  gauze  being  packed  into  this  pouch  after  its  inser- 
tion into  the  belly. 

28.  A  ruptured  varicose  vein  requires  a  compress,  a  band- 
age from  the  periphery  up,  and  elevation, 

29.  For  capillary  hemorrhage  use  hot  water  and  com- 
pression, or,  if  this  fails,  the  cauter}^  Understand  that  cap- 
illary bleeding  does  not  so  much  mean  bleeding  from  genu- 
ine capillaries  as  it  does  bleeding  from  arterioles  and  venules. 

30.  Pressure  above  a  wound  stops  arterial  hemorrhage, 
but  aggravates  venous  bleeding.  Pressure  below  a  wound 
stops  venous  hemorrhage,  but  increases  arterial  bleeding. 


254 


A   MANUAL    OF  SURGERY. 


31.  In  severe  epistaxis,  or  bleeding  from  the  nose,  pack 
the  nares.  Pass  a  Bellocq  canula  (Fig.  40)  along  the  floor 
of  one  nostril  into  the  pharynx,  project  the  stem  into  the 
mouth,  tie  a  plug  of  lint  or  gauze  to  the  stem,  and  with- 
draw it.  Carry  out  the  same  procedure  upon  the  other 
nostril,  pull  the  strings  firmly  forward,  pack  the  nostrils 
from  before  backward,  and  tie  the  strings  around  the  head. 
Soaking  the  lint  or  gauze  in  antipyrine  solution  is  a  good 


Fig.  40. — Plugging  the  Nares  for  Epistaxis  (Guerin). 


plan.  Do  not  use  subsulphate  of  iron,  as  it  forms  a  disgust- 
ing, clotty,  adherent  mass.  If  a  Bellocq  canula  is  not 
obtainable,  push  a  soft  catheter  into  the  pharynx,  catch  it 
with  a  finger,  pull  it  forward,  and  tie  the  plug  to  it. 

32.  In  gunshot  wounds  the  primary  hemorrhage  is  slight 
unless  a  large  vessel  is  cut.  The  bleeding  may  be  visible  or 
may  be  internal  (concealed),  the  blood  running  into  a  natu- 
ral cavity  or  among  the  muscles.    Capillary  oozing  is  arrested 


DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS.     255 

by  very  hot  water  and  compression.  Venous  bleeding  is 
usually  arrested  by  compression.  If  a  large  vessel  is  the 
source  of  bleeding,  enlarge  the  wound  and  tie  the  vessel. 
If  the  artery  cannot  be  found  in  the  wound,  tie  the  main 
trunk. 

33.  In  prolonged  bleeding  from  a  leech-bite,  try  compres- 
sion over  a  plug  saturated  with  alum  or  with  tannin.  If  this 
fails,  pass  under  the  wound  a  hare-lip  pin  and  encircle  it 
with  a  piece  of  silk.     If  this  fails,  use  the  actual  cautery. 

34.  In  severe  bleeding  from  the  ear,  elevate  the  head,  put 
an  ice-bag  over  the  mastoid,  give  opium  and  acetate  of  lead, 
and,  if  blood  runs  into  the  mouth,  plug  the  Eustachian  tube 
with  a  piece  of  catheter. 

35.  Umbilical  hemorrhage  in  infants  requires  pressure 
over  a  plug  containing  tannin  or  alum.  If  this  fails,  pass 
hare-lip  pins  under  the  navel  and  apply  a  twisted  suture. 
If  this  fails,  use  the  actual  cautery. 

36.  Rectal  bleeding  requires  elevation  of  the  buttocks, 
insertion  of  plugs  of  ice,  ice  to  the  anus  and  perineum, 
astringent  injections  (alum),  and  the  internal  use  of  opium, 
ergot,  and  acetate  of  lead.  If  these  means  fail,  plug  the 
bowel  over  a  catheter,  or  insert  and  inflate  a  Peterson  bag  or 
a  colpeurynter,  or  tampon  and  use  a  T-bandge.  If  the  bleed- 
ing persists  or  if  a  considerable  vessel  is  bleeding,  stretch 
the  sphincter,  catch  the  bowel  and  draw  it  down,  seize  the 
vessel,  and  tie  it  if  possible ;  if  not,  leave  the  forceps  in 
place.     Failing  in  this,  the  actual  cautery  must  be  used. 

^^j .  Subcutaneous  hemorrhage,  if  severe,  demands  that  an 
incision  be  made  and  ligation  be  performed. 

38.  Bleeding  from  a  cut  urethral  meatus  requires  the 
insertion  of  styptic  cotton  and  the  application  of  pressure. 
Moderate  bleeding  from  the  urethra  can  usually  be  arrested 
by  a  hot  bougie,  by  hot  injections,  or  by  tying  a  condom 
over  a  catheter,  and,  after  inserting  it,  inflating  the  condom 


256  A    MANUAL    OF  SURGERY. 

by  blowing  through  the  catheter  and  plugging  the  orifice 
of  the  instrument,  thus  using  pressure.  Sitting  with  the 
perineum  on  a  thickly-folded  towel  is  useful.  Ice  to  the 
perineum  does  good.  If  these  means  are  futile,  perform  an 
external  urethrotomy  and  reach  the  bleeding  point. 

39.  Hemorrhage  from  the  prostate  requires  hot  injec- 
tions, the  introduction  of  a  large  bougie  first  dipped  in 
very  warm  water,  and  the  retention  of  a  catheter  for  two 
days.  Perineal  section  may  be  required,  or  suprapubic  cyst- 
otomy with  packing  which  does  not  occlude  the  ureteral 
orifices. 

40.  Vesical  hemorrhage  usually  ceases  spontaneously,  in 
which  case  the  urine  must  be  drawn  off  and  the  viscus  be 
washed  out  frequently  with  a  solution  of  boric  acid  to  pre- 
vent septic  cystitis.  If  blood-clots  prevent  the  flow  of  urine, 
break  them  up  with  a  catheter  and  inject  vinegar  and  water. 
Perfect  quiet  is  to  be  maintained,  cold  acid  drinks  to  be 
given,  ice-bags  to  be  put  to  the  perineum  and  hypogastric 
region,  and  opium  w^ith  acetate  of  lead,  ergot,  or  gallic  acid 
to  be  given  by  the  mouth.  If  the  hemorrhage  is  severe  or 
persistent,  perform  a  suprapubic  cystotomy. 

41.  In  hemorrhage  after  lateral  lithotomy,  ligate  if  pos- 
sible. If  the  vessel  can  be  caught  but  cannot  be  ligated, 
leave  the  forceps  in  place.  If  we  cannot  catch  the  vessel 
with  forceps,  try  a  tenaculum.  If  the  tenaculum  fails,  pass  a 
threaded  curved  needle  through  the  tissues  around  the  ves- 
sel and  tie  the  ligature.  Plugs  of  ice  and  injections  of  hot 
water  may  be  tried.  These  means  failing,  pressure  is  indi- 
cated. Take  a  canula,  fasten  to  it  a  chemise  (Fig.  41), 
empty  clots  from  the  bladder,  insert  the  instrument  into  the 
viscus,  and  pack  gauze  between  the  sides  of  the  canula  and 
the  chemise.  The  chemise  is  bulged  out  and  pressure  is 
made.  Tie  the  canula  by  means  of  tapes  to  a  T-bandage. 
Pressure  is  thus  combined  with  vesical  drainage.    Buckstone 


DISEASES  AND   INJURIES   OF  HEART  AND    VESSEIS.     257 


Brown  makes   pressure  by  inflating  a  rubber  bag  with  air. 
The    hot    iron  may  occasionally  be  demanded. 

42.  Renal  bleeding  requires  ice  to  the  loin,  tannic  acid 
and  opium,  gallic  acid  and  sulphuric 
acid,  ergot,  and  perfect  quiet.  If  the 
bleeding  threatens  life  and  the  dis- 
eased organ  is  identified,  perform  a 
lumbar  nephrectomy;  if  not  sure  which 
organ  is  diseased,  perform  an  abdom- 
inal nephrectomy. 

43.  Vaginal  hemorrhage  requires  the 
ligature  or  the  tampon. 

44.  Severe  uterine  hemorrhage  (un- 
connected with  pregnancy)  requires  the 
tampon.  Persistent  hemorrhage  due  to 
morbid  growths  may  require  removal 
of  the  tubes  and  appendages,  ligation 
of  the  uterine  and  ovarian  arteries,  or 
hysterectomy. 

45.  Haematemesis,  or  bleeding  from 
the  stomach,  is  treated  by  the  swallowing  of  ice,  giving 
tannic  acid  (dose,  20  or  30  grains)  or  Monsel's  solution 
(3  drops).  Never  give  tannic  acid  and  Monsel's  solution  at 
the  same  time,  as  they  mix  and  form  ink.  Opium  is  usually 
ordered.  Acetate  of  lead  and  opium  and  gallic  acid  are 
favorite  remedies,  and  ergot  is  used  by  many.     Give  no  food. 

46.  In  bleeding  from  the  small  bowel,  give  acetate  of  lead 
and  opium,  sulphuric  acid,  ergot,  or  Monsel's  salt  in  pill 
form  (3  grains),  allow  no  food  for  a  time,  and  insist  on  liquid 
diet  for  a  considerable  period. 

47.  In  bleeding  from  the  large  bowel,  use  styptic  injections 
(10  grains  of  alum  or  5  grains  of  bluestone  to  5J  of  water). 
If  bleeding  is  low  down,  use  small  amounts  of  the  solution; 
if  high  up,  large  amounts.     Do  not  use  absorbable  poisons. 

17 


Fig.  41. — Canula  a  Chemise. 


258  A   MANUAL    OF  SURGERY. 

48.  HcTemoptysis,  or  bleeding  from  the  lung,  is  treated  by 
morphia  hypodermatically,  by  perfect  rest,  by  dry  cups  or 
ice  ov^er  the  affected  spot  if  it  can  be  located,  by  ergot,  and 
by  gallic  acid.     Gallic  acid  aids  coagulation.^ 

Reactionary  or  Recurrent  Hemorrhag-e  (called  also 
Consecutive,  Intermediate,  or  Intercurrent). — This  form  of 
hemorrhage  comes  on  during  reaction  from  an  accident  or 
an  operation — that  is,  during  the  first  forty-eight  hours.  It 
is  usually  due  to  badly-applied  ligatures,  or  may  result  from 
vascular  excitement  or  from  hypertrophied  heart,  the  jump- 
ing arteries  loosening  the  ligature.  The  Esmarch  apparatus 
is  not  unusually  the  cause.  The  constricting  band  paralyzes 
the  smaller  arteries,  which  do  not  bleed  during  shock  and 
do  not  contract  as  shock  departs ;  hence  bleeding  comes  on 
with  reaction.  To  lessen  the  danger  of  the  Esmarch  appa- 
ratus, use  a  broad  constricting  band  rather  than  a  rubber 
tube.  During  reaction  after  an  amputation,  if  slight  hemor- 
rhage occurs,  elevate  the  stump  and  compress  the  flaps. 
If  the  hemorrhage  persists  or  at  any  time  becomes  severe, 
make  pressure  on  the  main  artery  of  the  limb,  open  the 
flaps,  turn  out  the  clots,  find  the  bleeding  point,  ligate,  asep- 
ticize, close,  and  dress.  In  any  severe  reactionary  hemor- 
rhage, open  the  wound  at  once  and  ligate. 

Secondary  hemorrhag-e  may  occur  at  any  time  in  the 
period  between  forty-eight  hours  after  the  accident  or  opera- 
tion and  the  complete  cicatrization  of  the  wound.  Secondary 
hemorrhage  may  be  due  to  atheroma,  to  slipping  of  a  liga- 
ture, to  inclusion  of  nerve,  fascia,  or  muscle  in  the  ligature, 
to  sloughing,  to  erysipelas,  to  septicaemia,  to  pyaemia,  to 
gangrene,  and    to    overaction  of  the    heart.     If  during   an 

^  The  use  of  ergot  is  a  general  but  questionable  practice.  Bartholow  and  others 
hold  that  this  drug  does  harm ;  it  contracts  all  the  arterioles,  and  hence  more 
blood  flows  from  an  area  where  there  is  damage.  Purgatives  do  good  in  bleed- 
ing from  the  lung  by  taking  blood  to  the  abdomen  and  lowering  blood-pressure. 


DISEASES  AND   IXJURIES   OF  HEART  AND    VESSELS.    259 

operation  the  vessels  are  found  atheromatous,  acupressure 
had  best  be  used,  or  pass  a  thread,  by  means  of  a  Hagedorn 
needle,  around  the  vessel,  including  a  cushion  of  tissue  in 
the  loop  of  the  ligature  (this  prevents  cutting  through). 
One  great  trouble  with  atheromatous  arteries  is  that  their 
coats  cannot  retract ;  another  trouble  is  that  the  ligature  cuts 
entirely  through  them.  If  after  an  operation  the  pulse  is 
found  to  be  forcible,  rapid,  and  jerking,  give  aconite,  opium, 
and  low  diet. 

Treatment  of  Secondary  Hemorrhage. — The  method  of 
treatment,  supposing  a  case  of  leg-amputation  in  which, 
several  days  after  the  operation,  a  little  oozing  is  detected,  is 
to  elevate  the  stump,  apply  two  compresses  over  the  flaps, 
and  carry  a  firm  bandage  up  the  leg.  If  the  bleeding  is  pro- 
fuse or  becomes  so,  make  pressure  on  the  main  artery,  open 
and  tear  the  flaps  apart  with  the  fingers,  find  the  bleeding 
vessel  and  tie  it,  turn  out  the  clots,  asepticize,  close,  and 
dress.  If  the  bleeding  begins  at  a  period  when  the  stump 
is  nearly  healed,  cut  down  on  the  main  artery  just  above  the 
stump  and  ligate.  In  secondary  hemorrhage  from  a  blood- 
vessel in  nodular  tissue,  throw  a  ligature  around  the  vessel 
by  a  curved  needle  and  tie  higher  up,  or,  if  this  fails,  ampu- 
tate. When  secondary  hemorrhage  arises  in  a  sloughing 
wound,  apply  a  tourniquet  or  an  Esmarch  bandage,  tear  the 
wound  open  to  the  bottom  with  a  grooved  director,  look  for 
the  orifice  of  the  vessel,  dissect  the  artery  up  and  down  until 
a  healthy  point  is  reached,  and  tie  both  ends.  If  this  fails, 
include  tissue  in  the  ligature  or  use  acupressure.  In  sec- 
ondary hemorrhage  from  atheromatous  vessels,  use  acupres- 
sure or  include  surrounding  tissue  in  the  ligature. 

Secondary  hemorrhage  may  occur  after  ligation  in  con- 
tinuity, the  blood  usually  coming  from  the  distal  side.  If 
the  dressings  are  slightly  stained  with  blood,  put  on  a  gradu- 
ated compress.     If  the  bleeding  continues  or  is  severe,  make 


260  A   MANUAL    OF  SURGERY. 

pressure  on  the  main  artery  of  the  Hmb,  open  the  wound  and 
Hgate,  wrap  the  part  in  cotton,  elevate,  and  surround  with  hot 
bottles.  If  this  re-ligation  is  done  on  the  femoral  and  fails, 
do  not  ligate  higher  up,  as  gangrene  will  certainly  occur,  but 
amputate  at  once,  above  the  point  of  hemorrhage.  If  dealing 
with  the  brachial  artery,  do  not  amputate,  but  ligate  higher 
up  and  make  compression  in  the  wound.  In  a  secondary 
hemorrhage  from  the  innominate,  tie  the  vertebral.  The 
best  way  to  deal  with  secondary  hemorrhage  is  not  to  have 
it,  and  thorough  antisepsis  is  the  greatest  possible  safeguard. 

2.   Operations  on  the  Vascular  System. 

Paracentesis  auriculi,  or  tapping  the  heart-cavity,  has 
been  sues'ested  for  the  relief  of  an  over-distended  heart 
from  pulmonary  congestion.  The  right  auricle  should  be 
tapped.  Push  the  aspirator-needle  directly  backward  at  the 
right  edge  of  the  sternum,  in  the  third  interspace.  This 
operation  is  not  recommended,  as  it  is  highly  dangerous 
and  is  of  questionable  value. 

Paracentesis  pericardii,  or  tapping  the  pericardial  sac,  is 
only  done  when  life  is  endangered.  Introduce  the  needle 
two  inches  to  the  left  of  the  left  edge  of  the  sternum,  in  the 
fifth  interspace,  and  push  it  directly  backward  (thus  avoiding 
the  internal  mammary  artery). 

Operation  for  Varix  of  Leg". — In  this  operation,  make, 
at  several  points  in  the  course  of  the  long  saphenous  vein, 
skin  incisions  each  two  inches  long  and  in  the  long  axis  of 
the  vessel.  Clear  the  vessel  at  each  incision,  apply  two  liga- 
tures an  inch  apart,  and  excise  the  vein  between  them.  Never 
operate  if  the  slightest  phlebitis  exists  (Barker).  Another 
method  is  as  follows  :  The  patient  stands  for  a  time  before 
a  fire  to  enlarge  the  veins.  A  hare-lip  pin  is  pushed  into  the 
tissues  an  inch  from  the  vein,  at  the  upper  end  of  its  varicose 
portion ;  the  pin  is  passed  under  the  vein  and  emerges  an 


DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS.     26 1 

inch  outside  of  it.  A  bit  of  catheter  wrapped  in  gauze  is 
laid  over  the  vein,  and  a  twisted  suture  is  carried  around  the 
pin  and  over  the  pad.  This  operation  is  done  lower  down  in 
one  or  two  positions. 

Open  Operation  for  Varicocele. — The  open  operation  is 
by  far  the  best  procedure  for  varicocele.  The  instruments 
used  are  a  scalpel,  an  aneurysm-needle,  a  Reverdin  needle, 
a  grooved  director,  a  dissecting-forceps,  an  Allis  dry  dis- 
sector, haemostatic  forceps,  and   scissors. 

Operation. — The  patient  is  recumbent  and  anaesthetized. 
The  operator  stands  on  the  diseased  side.  The  assistant 
stands  on  the  sound  side  and  makes  pressure  over  the  inguinal 
ring  of  the  affected  side.  A  fold  of  skin  is  pinched  up  on 
the  scrotum,  and  the  surgeon  transfixes  it  in  the  line  of  the 
cord,  so  that  he  will  have  an  incision  about  one  and  a  half 
inches  long  running  downward  from  below  the  external 
ring.  The  veins  are  reached  by  means  of  an  Allis  dissector 
and  the  cord  is  located  and  held  aside.  A  double  ligature 
of  silk  is  passed  under  the  veins  by  an  aneurysm-needle. 
The  threads  are  separated  three-quarters  of  an  inch,  tied 
tightly,  and  cut.  The  veins  between  the  ligatures  are 
divided  or  excised.  The  scrotum  is  sewed  up  with  silk- 
worm gut,  a  small  drainage-tube  being  used  for  twenty-four 
hours.  Healing  is  complete  in  one  week.  Dr.  Hearn,  after 
resecting  a  portion  of  the  vein-mass,  ties  the  cut  ends  together 
and  thus  shortens  the  veins. 

Subcutaneous  Ligature  for  Varicocele. — In  this  opera- 
tion, employ  every  antiseptic  precaution.  The  patient  stands, 
and  the  operator,  sitting  in  front  of  him,  holds  the  veins  in  a 
fold  of  skin  away  from  the  vas  deferens. by  means  of  the 
thumb  and  index  finger  of  the  left  hand.  A  large  straight 
needle  carrying  a  double  piece  of  strong  silk  is  passed 
entirely  through  the  scrotum,  between  the  veins  and  the 
vas.     The    needle   is  again   inserted   at  the    puncture   from 


262 


A   MANUAL    OF  SURGERY. 


which  it  emerged,  is  carried  around  under  the  skin  and  in 
front  of  the  veins,  and  emerges  at  its  original  point  of  entry. 
The  veins  are  thus  surrounded  by  the  silk.  The  patient, 
who  now  lies  down,  is  placed  under  the  first  stage  of  ether, 
and  the  double  ligatures  are  separated  as  far  as  possible  from 
each  other,  tied,  and  cut  off,  the  knots  slipping  in  through 
the  puncture.  This  operation  presents  certain  dangers.  The 
veins  may  be  w^ounded  and  the  vas  or  other  structures  may 
be  included.  In  an  operation  it  is  always  best  to  be  able  to 
see  what  we  are  doing ;  hence  the  open  operation  is  preferred 
to  the  subcutaneous. 

Phlebotomy,  or  Venesection. — The  instruments  used  in 
venesection  are  a  lancet  or  bistoury,  a  broom-handle,  a 
fillet  or  tape,  an  antiseptic  pad,  and  a  bandage. 

Operation. — The  patient  sits  on  a  chair  "  with  the  arm 
abducted,  extended,  and  inclined  outward  "  (Barker).     The 

surgeon  stands  to  the  right 
of  the  arm,  holds  the  elbow 
with  his  left  hand,  and  puts 
his  thumb  upon  the  vein 
below  the  intended  point 
of  puncture.  Asepticize  the 
parts  and  tie  the  tape  above 
the  elbow.  The  patient 
grasps  the  stick  firmly  and 
works  his  fingers  to  swell 

for  Venesection. 

Elbow.         (Bernard  and  Huette.)  the  vcins.  Either  thc  median 

cephalic  or  median  basilic  can  be  punctured  (Fig.  43).  The 
median  basilic  is  the  more  distinct,  and  is  the  vein  usually 
selected.  In  puncturing  it,  do  not  go  too  deep,  as  nothing 
but  the  bicipital  fascia  separates  it  from  the  brachial  artery. 
The  median  cephalic  may  be  selected  (we  thus  avoid  en- 
dangering the  brachial  artery),  but  remember  that  under  this 
vein  lies  the  external  cutaneous  nerve  (Fig.  42).     Steady  the 


\  IG   42  — Superficial 
Veins  in  Front  of  the 


Fig.  43. — Incisions 


DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS.     263 

vein  with  the  thumb  and  open  it  by  transfixion,  making  an 
obHque  cut  which  divides  two -thirds  of  it.  Remove  the 
thumb  and  allow  bleeding  to  go  on,  instructing  the  patient 
to  work  his  fingers.  When  faintness  begins,  remove  the  fillet, 
put  an  antiseptic  pad  over  the  puncture,  apply  a  spiral  reverse 
bandage  of  the  hand  and  arm  and  a  figure-of-8  bandage  of 
the  elbow,  and  place  the  arm  in  a  sling  for  several  days. 

Transfusion  of  Blood. — This  operation  has  been  a  recog- 
nized procedure  since  1824,  though  it  has  certainly  been 
known  since  1492,  when  transfusion  in  the  case  of  Pope 
Innocent  VIII.  was  made.  Its  chief  use  is  in  severe  hemor- 
rhage, especially  post-partum,  in  which  it  replaces  the 
blood  lost  and  supplies  something  for  the  heart  to  con- 
tract upon  until  new  blood  is  formed.  That  it  saves  life 
is  unquestionable,  but  the  procedure  falls  short,  in  per- 
manent result,  of  what  was  anticipated  for  it.  The  old 
view  was  that  blood  must  come  from  the  same  animal^ 
but  Brown-Sequard  demonstrated  that  the  blood  of  various 
animals  could  be  used,  and  Panum  proved  that  defibrinated 
blood  is  as  efficient  as  pure  blood.  This  discovery  of 
Panum  indicates  that  the  saline  elements  are  those  which 
are  required  ;  hence  at  the  present  day  a  saline  fluid  is  more 
often  transfused  than  blood.  This  fluid  is  generally  thrown 
into  the  cellular  tissue  rather  than  into  the  veins.  In  saline 
injection  by  hypodermoclysis,  which  is  so  useful  in  col- 
lapse, from  ten  to  sixteen  ounces  of  warm  normal  salt-solu- 
tion are  gradually  passed  into  the  cellular  tissue  by  means  of 
a  fountain-syringe  and  a  large  aspirating-needle,  the  region  of 
injection  being  rubbed  and  kneaded.  Some  ph}\sicians  inject 
a  solution  consisting  of  boiled  water  and  phosphate  of  soda. 

Transfusion  of  blood  may  be  mediate.  A  thoroughly 
healthy  man  is  bled  from  the  median  basilic  vein,  the  blood 
being  caught  in  an  aseptic  tumbler  which  stands  in  a  basin 
of  water  at  100°  F.     The  heat  prevents  coagulation  of  the 


264 


A   MANUAL    OF  SURGERY. 


blood,  which  is  defibrinated  by  whipping  with  a  clean  fork. 
The  median  basilic  vein  of  the  sufferer  is  exposed  by  an  in- 
cision, and  is  lifted  up  from  its  bed  by  a  probe  and  opened. 
There  are  sucked  up  in  an  aseptic  syringe  two  ounces  of 
blood,  which  is  at  onc(^  injected  into  the  vein  of  the  patient ; 
two  ounces  more  are  allowed  to  run  from  the  donor  and 
are  defibrinated,  and  two  ounces  more  are  thrown  into  the 
veins  of  the  recipient,  in  the  interval  pressure  being  used 
to  prevent  bleeding.  There  are  thus  introduced  ten,  twelve, 
or  sixteen  ounces.  The  chief  dangers  are  embolism,  sepsis, 
and  the  entrance  of  air. 

Transfusion  of  blood  may   be  immediate.     Expose   with 
antiseptic  care  a  vein  of  the  donor  at  the  bend  of  the  elbow 


Fig.  44. — Aveling's  Apparatus  for  Immediate  Transfusion. 

and  a  vein  of  the  recipient  in  the  same  situation,  fillets  being 
tied  above  each  elbow.  The  veins  must  be  thoroughly  bared 
to  the  extent  of  three-quarters  of  an  inch.  Open  the  veins 
and  introduce  the  canulae  of  an  Aveling  syringe  (Fig.  44), 
which  instrument  is  filled  with  normal  salt-solution.  The 
opening  is  small  and  transverse.  The  canula  in  the  vein  of 
the  donor  is  pushed  toward  the  hand,  that  in  the  vein  of  the 
recipient  being  pushed  toward  the  .shoulder,  the  arms  of 
giver  and  receiver  resting  upon  a  table.  Remove  the  fillets. 
Compress  the  tube  between  the  bulb  and  the  giver,  open  the 
clips,  squeeze  the  bulb  to  drive  the   salt-solution  into  the 


LIGATIONS. 


Plate  3. 


I.  Opening  the  Sheath  for  Ligation  of  an  Artery  (Guerin).  2.  Sheath  of  Artery  Open  (Guerin). 
3.  Tightening  the  Knot  in  Ligation  (Guerin).  4.  Anatomy  of  the  Iliac  Arteries,  and  showing  the 
lines  of  incision  for  their  ligation  :  i,  Abernethy's  incision  (Guerin).  5,  6.  Ballance  and  Ed- 
mund's Stay-knots. 


DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS.     265 

giver,  remove  the  pressure  from  the  tube  between  the  bulb 
and  the  donor,  compress  the  tube  between  the  bulb  and  the 
recipient,  and  allow  the  bulb  to  expand  and  fill  with  blood  ; 
force  this  blood  out  by  the  same  plan,  and  thus  continue  until 
six,  eight,  or  ten  ounces  are  transferred.  Dress  each  patient  as 
after  phlebotomy.  Saline  transfusion  is  sometimes  performed. 
Arterial  Transftision. — Hueter  prefers  the  arterial  method 
of  transfusion,  in  order  to  send  the  blood  more  gradually  to 
the  heart,  and  thus  prevent  sudden  disturbance  of  the  circula- 
tion. A  little  air  in  an  artery  will  do  no  harm,  and  the  danger 
of  venous  embolism  is  avoided.  The  radial  artery  is  exposed 
and  surrounded  by  three  ligatures,  and  the  thread  toward 
the  heart  is  at  once  tied.  The  distal  ligature  is  slightly 
tightened  to  cut  off  anastomotic  blood-supply.  The  artery 
is  cut  transversely  half  through ;  the  syringe  is  inserted, 
pointed  toward  the  periphery,  and  fastened  by  the  third 
ligature ;  the  second  ligature  is  loosened  and  the  blood  is  in- 
jected. On  finishing,  the  peripheral  thread  is  tied  tightly  and 
that  portion  of  the  artery  which  held  the  canula  is  excised. 

3.  Ligation  of  Arteries  in  Continuity. 

The  instruments  used  in  this  operation  are  two  scalpels  (one 
small,  one  medium],  two  dissecting-forceps,  several  haemo- 
static forceps,  toothed  forceps,  blunt  hooks  or  broad  metal 
retractors,  an  Allis  dissector,  an  aneurysm-needle^  for  super- 
ficial arteries  the  instrument  of  Saviard,  for  deep  vessels  the 
needle  of  Dupuytren,  ligatures  of  catgut,  of  chromicized  gut, 
or  of  silk,  and  the  reflector  or  electric  forehead-lamp  for  deep 
vessels. 

The  position  varies  according  to  the  vessel,  though  the 
body  is  supine  except  when  ligation  is  to  be  performed  on  the 
gluteal,  sciatic,  or  popliteal.  The  operator,  as  a  rule,  stands 
upon  the  affected  side,  cutting  from  above  downward  on  the 
right  side  and  from  below  upward  on  the  left  side. 


266  A   MANUAL    OF  SURGERY. 

Operatioji. — Accurately  determine  the  line  of  the  artery, 
and  make  an  incision  at  an  angle  of  five  degrees  to  this  line, 
avoiding  subcutaneous  veins,  and  holding  the  scalpel  like 
a  fiddle-bow  or  a  dinner-knife  while  cutting  the  superficial 
parts,  and  like  a  pen  while  incising  the  deeper  parts.  On 
reaching  the  deep  fascia,  make  out  the  required  muscular 
gap  by  the  eye  and  finger,  so  moving  the  extremity  as  to 
bring  individual  muscles  into  action.  Treves  cautions  us  not 
to  depend  upon  the  yellow  line  of  fat,  which  often  cannot 
be  seen  in  emaciated  people  or  when  an  Esmarch  bandage 
is  employed;  nor  upon  the  white  line  due  to  attachment  to 
the  fascia  of  an  intermuscular  septum.  In  opening  the  deep 
portion  of  the  wound,  relax  the  bounding  muscles  by  altering 
the  posture.  Open  a  muscular  interspace  with  the  knife  or 
the  Allis  dissector.  Make  the  depths  of  the  wound  as  long 
as  the  superficial  incision.  Do  not  tear  structures  apart 
with  a  grooved  director  (Treves).  Arrest  hemorrhage  as  it 
occurs.  Try  to  find  the  situation  of  the  artery  with  the 
finger.  Pulsation  is  present,  but  it  may  be  very  feeble  and 
hard  to  detect.  The  artery  feels  like  a  very  thin  rubber 
tube  ;  it  is  compressible,  though  not  so  easily  as  a  vein, 
and  when  compressed  feels  like  a  flat  band  which  is  thinner 
in  the  centre  than  at  the  edges  (Treves).  A  nerve  feels  like 
a  hard  round  cord.  The  veins  are  soft,  larger  than  their 
related  arteries,  and  so  very  compressible  that  they  can 
scarcely  be  felt  when  pressed  upon,  compression  causing 
distal  distention.  If  the  wound  can  be  seen  well  into,  it  will 
be  noted,  as  Treves  asserts,  that  "  the  nerves  stand  out  as 
clear,  rounded,  white  cords ;  that  the  veins  are  of  a  purple 
color  and  of  somewhat  uneven  and  wavy  contour;  that  the 
artery  is  regular  in  outline  and  of  a  pale-pink  or  pinkish- 
yellow  tint,  the  large  vessels  being  of  lighter  color  than  the 
small."  All  the  arteries  of  the  upper  extremity  and  all  the 
arteries  below  the  knee  are  accompanied  by  two  veins  known 


DISEASES  AXD   INJURIES   OF  HEART  AND    VESSEIS.     267 

as   "  ven^E   comites."     The  arteries   of  the   head   and   neck 
have  each  a  single  attending  vein,  except  the  Ungual,  which 
has  venae  comites.     Most  of  the  smaller  arteries  of  the  trunk 
(pudic,  internal  mammary,  etc.)  have  venae  comites.     These 
companion  veins  may  lie  on  each  side  of  the  artery  or  in 
front  and  back  of  it,  and  they  communicate  with  one  another 
by  transverse  branches  crossing  the  artery.    On  reaching  the 
sheath;  pick  up  this  structure  with  toothed  forceps  so  as  to 
make  a  transverse  fold,  and  thus  avoid  catching  the  artery  or 
vein  ;  lift  the  fold  to  see  that  it  is  free,  and  open  the  sheath  by 
cutting  toward  the  edge  of  the  forceps  with  a  scalpel  held 
obliquely  with  its  back  toward  the  vessel,  thus  making  a  Small 
longitudinal  incision  (PL  3,  Figs,  i,  2).    Hold  the  edge  of  the 
incised  sheath  with  the  forceps;   pass  an  aneurysm-needle 
under  the  vessel  and  from  the  forceps  ;  this  clears  one-half 
of  the  vessel.     Grasp  the  other  edge  of  the  sheath  and  pass 
the  aneurysm-needle  all  the  way  around  the  vessel,  threading 
the  needle  when  it  emerges  and  withdrawing  it.     In  passing 
the  needle  this  last  time,  carry  it  away  from  its  most  dan- 
gerous neighbor.     If  venae  comites  are  in  the  way,  try  and 
separate  them,  but  if  this  proves  difficult,  include  them  in 
the  ligature.     In  small  vessels  always   include  them  if  they 
are  in  the  way,   as  this   saves  trouble.     If,  in   passing  the 
needle,  a  large  vein  is  severely  wounded  (such  as  the  femoral), 
Jacobson  advises  the  employment 
of  digital  pressure  in  the  lower 
portion  of  the  wound  while  the 
artery   is   being  tied    on   a  level 
above  or  below  that  of  the  vein- 

•_:  1  n  1-        ,•  1  Fig.  4^. — Reef-knot. 

mjury,    and    after    ligation    the 

maintenance  of  pressure  on  the  wound  for  a  couple  of  days. 
A  slight  puncture  in  a  vein  merel\'  requires  a  lateral  liga- 
ture. After  getting  a  ligature  under  an  artery,  press  for  a 
moment  upon  the  artery  over  the  ligature,  which  is  held  taut ; 


268  A   MANUAL    OF  SURGERY. 

this  pressure  will  show  that  pulsation  below  is  arrested.  Tie 
the  thread  at  right  angles  to  the  vessel  with  a  reef-knot  (Fig. 
45),  rupturing  the  internal  and  middle  coats.  As  the  ligature 
is  tightened  place  the  extended  index  fingers  along  the  liga- 
ture up  to  the  artery  (PI.  3,  Fig.  3),  using  the  middle  joints 
as  the  fulcrum  of  a  lever  by  placing  them  against  each  other. 

Ballance  and  Edmunds  have  recently  claimed,  as  Scarpa 
and  Sir  Philip  Crampton  did  long  since,  that  it  is  not  neces- 
sary to  divide  the  internal  and  middle  coats  to  ensure  oblit- 
eration. If  this  claim  be  true,  the  danger  of  secondary 
hemorrhage  can  be  greatly  lessened.  Holmes,  however, 
thinks  the  older  method  the  more  certain  of  the  two. 
Ballance  and  Edmunds  recommend  that  the  artery  be  sur- 
rounded with  a  doubled  ligature  of  floss-silk,  that  each 
ligature  be  tied  with  one  turn  of  a  reef-knot,  and  that  the 
final  turn  be  made  by  gathering  together  as  single  pieces 
both  ends  of  each  ligature  and  tying  them  to  each  other. 
This  knot  is  known   as  the  "stay-knot"  (PL  3,  Figs.  5,  6). 

The  chief  dangers  after  ligation  are  secondary  hemorrhage 
and  gangrene.  Rigid  asepsis  usually  prevents  the  first;  rest, 
elevation,  and  heat  antagonize  the  second. 

Radial  Artery. — The  Hue  of  the  radial  artery  is  from  the 
middle  of  the  front  of  the  elbow-joint  to  the  front  of  the 
styloid  process  of  the  radius.  The  line  in  the  tabatiere  is 
from  the  apex  of  the  styloid  process  to  the  posterior  angle 
of  the  first  interosseous  space. 

Anatomy  (PL  4,  Fig.  5). — The  radial  artery,  though  smaller 
than  the  ulnar,  is  the  direct  continuation  of  the  brachial. 
It  arises  from  the  bifurcation  of  the  brachial,  half  an  inch 
below  the  bend  of  the  elbow,  runs  down  the  radial  side  of 
the  forearm  to  the  front  of  the  styloid  process  of  the  radius, 
passes  beneath  the  extensor  muscles  of  the  first  metacarpal 
bone  and  of  the  first  phalanx  of  the  thumb,  and  over  the  car- 
pus to  the  first  interosseous  space,  where  it  is  crossed  by  the 


LIGATIONS. 


Plate  4. 


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DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS.     269 

extensor  secundi  internodii  pollicis,  and  enters  into  the  palm 
between  the  heads  of  the  first  dorsal  interosseous  muscle  to 
form  the  deep  palmar  arch.  The  artery  in  the  upper  part 
of  its  course  is  somewhat  overlaid  by  the  supinator  longus 
muscle ;  throughout  the  rest  of  the  forearm  it  is  superficial. 
In  the  upper  third  of  the  forearm  it  lies  between  the  supi- 
nator longus  on  the  outside  and  the  pronator  radii  teres  on 
the  inside ;  in  the  lower  two-thirds  of  the  forearm  it  lies 
between  the  supinator  longus  on  the  outside  and  the  flexor 
carpi  radialis  on  the  inside.  The  radial  nerve  is  to  the  outer 
or  radial  side  of  the  artery,  well  removed  fromi  the  artery  in 
the  upper  third,  nearer  to  the  artery  in  the  middle  third,  far 
external  to  the  artery  in  the  lower  third,  the  nerve  at  this 
point  passing  beneath  the  supinator  longus  muscle.  The 
radial  artery,  from  above  downward,  rests  upon  the  biceps 
tendon,  the  short  supinator  muscle,  the  pronator  radii  teres 
muscle,  the  flexor  sublimis,  the  flexor  longus  pollicis,  the 
pronator  quadratus  muscles,  and  the  radius.  It  has  two 
venae  comites.  The  best  guide  to  the  radial  artery  in  the 
forearm  is  the  outer  edge  of  the  flexor  carpi  radialis  muscle 
or  the  inner  edge  of  the  supinator  longus  muscle. 

The  tabatiere,  or  snuff-box,  is  an  anatomical  triangle  whose 
base  is  the  lower  edge  of  the  posterior  annular  ligament, 
one  side  being  formed  by  the  extensor  secundi  internodii 
pollicis  tendon,  the  other  by  the  extensor  ossis  metacarpi 
and  the  extensor  primi  internodii  pollicis  tendons  ;  the  floor 
consists  of  the  trapezium,  scaphoid,  and  base  of  the  first 
metacarpal  bone. 

Operations :  Ligation  in  the  tabatiere  is  a  dissecting-room 
operation  of  but  little  practical  use. 

Ligation  in  the  Loiver  Third. — In  this  operation  (PI.  4, 
Fig.  6)  the  forearm  is  supinated  and  held  by  an  assistant. 
The  surgeon  stands  on  the  side  operated  upon,  and  cuts 
from    above    downward  on  the  right  arm  and  from  below 


270  A    MANUAL    OF  SURGERY. 

upward  on  the  left  arm.  The  Hne  of  the  vessel  is  laid 
down  and  marked  with  iodine  or  aniline.  An  incision  one 
and  a  half  inches  long  is  made  at  an  angle  of  five  degrees 
to  this  line  and  midway  between  the  supinator  longus  and 
the  flexor  carpi  radialis  muscles,  which  incision  must  not 
extend  below  the  level  of  the  tuberosity  of  the  scaphoid 
bone.  In  the  superficial  fascia  watch  for  the  superficial 
radial  vein,  and  if  it  comes  into  view,  push  it  aside.  Incise 
the  superficial  fascia  and  locate  each  guide-tendon.  Open 
the  deep  fascia  in  the  length  of  the  first  cut ;  try  and 
separate  the  veins,  but  if  they  strongly  adhere,  include 
them  in  the  ligature.  There  is  no  special  fascial  sheath. 
The  radial  nerve  will  not  be  seen,  but  a  division  of  the 
anterior  cutaneous  is  frequently  found  in  relation  with  the 
vessel.  The  needle  can  be  passed  in  either  direction.  A 
high  origin  of  the  superficialis  volae  artery  is  confusing. 

Ligation  in  the  Middle  Third. — In  this  operation  the  posi- 
tion is  the  same  as  in  the  preceding.  A  two-inch  incision 
is  made.  Veins  of  the  subcutaneous  tissues  are  avoided. 
Lying  upon  the  deep  fascia  is  the  anterior  division  of  the 
musculo-cutaneous  nerve.  Open  the  fascia ;  find  the  inner 
edge  of  the  supinator  longus  muscle  and  draw  it  outward, 
flexing  the  elbow  if  necessary.  Be  sure  not  to  get  external 
to  this  muscle.  Find  the  vessel  where  it  is  bound  down  by 
connective  tissue  to  the  pronator  radii  teres  muscle,  separate 
the  veins,  and  pass  the  ligature  from  without  in.  The  nerve 
is  external. 

Ligation  in  the  Upper  Third. — In  this  operation  the  incision 
is  like  the  last,  only  higher  up.  The  artery  is  between  the 
supinator  longus  and  the  pronator  radii  teres,  which  muscles 
are  at  once  differentiated  by  the  different  direction  of  their 
fibres.  The  artery  is  usually  covered  by  the  supinator  longus 
muscle,  which  must  be  retracted  externally.  The  nerve  is 
not  seen.     The  ligature  is  passed  in  either  direction. 


DISEASES  AND   INJURIES   OE  HEART  AND    VESSELS.     2/1 

Ulnar  Artery. — No  one  line  will  overlie  the  entire  ulnar 
artery.  The  line  of  the  upper  third  runs  from  the  middle 
of  the  front  of  the  elbow-joint  to  the  point  of  junction  of 
the  upper  and  middle  thirds  of  the  ulna.  The  line  of  the 
lower  two-thirds  runs  from  the  tip  of  the  internal  condyle 
of  the  humerus  to  the  radial  side  of  the  pisiform  bone 
(PL  4,  Figs.  5,  6). 

Anatomy. — (PI.  4,  Fig.  5.)  The  ulnar  artery  arises  from 
the  brachial  bifurcation  and  runs  obliquely  inward  under  the 
median  nerve  and  a  group  of  muscles  from  the  internal 
condyle ;  it  turns  down  the  arm,  being  covered  in  the 
middle  third  of  its  course  by  the  flexor  carpi  ulnaris  muscle. 
In  the  lower  third  it  is  superficial,  between  the  tendons  of 
the  flexor  carpi  ulnaris  on  the  inside  and  the  flexor  sublimis 
digitorum  on  the  outside,  the  vessel  being  a  little  overlapped 
by  the  flexor  carpi  ulnaris.  This  vessel  rests  first  upon  the 
brachialis  anticus  muscle,  next  upon  the  flexor  profundus, 
to  which  it  is  bound  by  a  distinct  process  of  fascia,  and  next 
upon  the  annular  ligament,  which  structure  it  crosses  to 
become  the  superficial  palmar  arch.  Two  venae  comites 
attend  the  vessel.  In  the  upper  third  the  nerve  is  well  in- 
ternal, but  in  the  lower  two-thirds  the  nerve  lies  near  the 
artery  and  to  its  ulnar  side.  The  guide  is  the  outer  edge 
of  the  flexor  carpi   ulnaris. 

Operations  (PL  4,  Fig.  6) :  Ligation  in  the  Loiver  TJiird. — The 
position  in  this  operation  is  the  same  as  for  the  radial  artery. 
Make  a  two-inch  incision  to  the  radial  side  of  the  tendon 
of  the  flexor  carpi  ulnaris,  which  incision  is  not  taken  lower 
than  a  point  one  inch  above  the  pisiform  bone.  Avoid  the 
superficial  ulnar  vein  in  the  subcutaneous  tissue.  Open  the 
deep  fascia,  find  the  tendon  of  the  flexor  carpi  ulnaris,  flex  the 
wrist  and  draw  the  tendon  inward,  open  the  sheath  of  fascia, 
separate  veins  if  possible,  and  pass  the  ligature  from  within 
outward  to  avoid  the  nerve.     On  the  artery  is  the  palmar 


2/2  A   MANUAL    OF  SURGERY. 

cutaneous  branch  of  the  ulnar  nerve,  and  this  branch  must 
not  be  included  in  the  ligature. 

Ligation  in  the  Middle  Third. — In  this  operation  the  posi- 
tion is  the  same  as  in  the  preceding  one,  the  incision  being 
three  inches  long.  Avoid  the  anterior  ulnar  vein  and  the 
branches  of  the  internal  cutaneous  nerve  in  the  superficial 
fascia.  Open  the  deep  fascia  a  little  external  to  the  super- 
ficial cut  (Treves).  Find  the  space  between  the  flexor  carpi 
ulnaris  and  the  superficial  flexor,  feeling  with  the  index 
finger,  and  when  the  space  is  discovered,  flex  the  wrist, 
retract  the  flexor  carpi  ulnaris  inward  and  the  flexor  sublimis 
digitorum  outward,  open  the  fascia,  find  the  ulnar  nerve, 
look  external  to  it  for  the  artery,  clear  the  vessel,  separate 
the  venae  comites,  and  pass  the  needle  from  within  outward. 

Brachial  Artery. — The  line  of  the  brachial  artery  is  from 
the  junction  of  the  anterior  and  middle  thirds  of  the  outlet 
of  the  axilla,  the  arm  being  abducted  and  the  forearm  supi- 
nated,  to  the  middle  of  the  front  of  the  elbow-joint. 

Anatomy  (PI.  4,  Fig,  i). — The  brachial  artery  is  the  pro- 
longation of  the  axillary,  and  extends  from  the  lower  edge  of 
the  teres  major  muscle  to  half  an  inch  below  the  bend  of  the 
elbow,  where  it  divides  into  the  radial  and  ulnar.  It  lies  first 
to  the  inner  side  of  the  arm,  but  passes  to  the  front  of  the 
elbow.  It  is  crossed  by  no  muscle,  and  is  in  fact  superficial, 
barring  its  being  somewhat  overlaid  in  part  of  its  course  by 
the  edge  of  the  biceps  muscle.  The  median  nerve  is  outside 
above,  crosses  over  or  under  it  about  the  middle  of  the  arm, 
and  reaches  the  inside.  The  coraco-brachialis  and  biceps  mus- 
cles are  external,  and  both  often  overlap  the  vessel.  The  ulnar 
nerve  is  internal  above,  and  the  median  nerve  below,  the  mid- 
dle. The  basilic  vein  is  internal  to  the  artery,  being  outside 
the  deep  fascia  to  the  upper  third,  at  which  point  it  pierces  it. 
The  artery  above  is  separated  from  the  long  head  of  the 
triceps  by  the  musculo-spiral  nerve  and  superior  profunda 


LIGATIONS. 


Plate  5. 


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x: 


DISEASES  AND  INJURIES   OF  HEART  AND    VESSELS.    273 

artery  and  vein ;  it  rests  from  above  down  on  the  inner  head 
of  the  triceps,  the  coraco-brachiaHs,  and  the  brachiahs  anticus. 
The  jartery  is  covered  by  skin  and  by  superficial  and  deep 
fascia.  The  internal  cutaneous  nerve  lies  in  front  of  the 
artery,  upon  the  deep  fascia,  until  it  pierces  the  fascia  along 
with  the  basilic  vein.  The  artery  has  venae  comites,  and  in  its 
upper  third  has  also  the  basilic  vein  to  its  inner  side.  The 
guide  to  the  brachial  is  the  inner  edge  of  the  biceps.  Just 
in  front  of  the  elbow-joint  the  artery  lies  in  a  triangle  the 
base  of  which  is  formed  by  an  imaginary  transverse  line 
above  the  condyles,  the  apex  by  the  junction  of  the  pronator 
radii  teres  and  the  supinator  longus.  The  outer  line  is  the 
supinator  longus,  the  inner  is  the  pronator  radii  teres,  and 
the  floor  is  formed  by  the  brachialis  anticus  and  the  supinator 
brevis.  From  within  outward  the  triangle  contains  the 
median  nerve,  brachial  artery,  tendon  of  the  biceps,  anasto- 
mosis of  the  superior  profunda  and  radial  recurrent  arteries, 
and  the  musculo-spiral  nerve. 

Operations  :  Ligation  at  the  Bend  of  the  Elboiv. — In  this 
operation  (PL  4,  Fig.  2)  extend  the  arm  moderately  and 
abduct,  and  allow  it  to  lie  upon  its  posterior  aspect.  The 
forearm  is  supinated.  The  surgeon  stands  upon  the  side 
operated  upon,  and  cuts  from  above  downward  on  the  right 
side  and  from  below  upward  on  the  left  side.  Accurately 
locate  the  tendon  of  the  biceps  and  the  median  basilic  vein. 
An  incision  is  made  parallel  with  the  inner  edge  of  the 
biceps  tendon  and  two  inches  in  length,  the  centre  of  this 
cut  being  in  the  crease  of  the  elbow.  On  exposing  the 
median  basilic  vein,  retract  it  inward,  open  the  bicipital 
fascia,  clear  the  artery  of  fat,  separate  the  venae  comites, 
and  pass  the  ligature  from  within  outward  to  avoid  the 
median  nerve.  The  above  operation  is  not  frequently  per- 
formed. 

Ligation  in  t/ie  Middle  of  the  Ann. — In  this  operation  ex- 

18 


2/4  A   MANUAL    OF  SURGERY. 

tension  and  abduction  of  the  arm  and  supination  of  the  fore- 
arm are  made.  An  assistant  holds  the  forearm,  but  the  arm 
should  not  rest  upon  the  table,  because,  if  it  be  allowed  to 
do  so,  the  inner  head  of  the  triceps  will  be  forced  forward 
and  may  overlie  the  artery,. and  thus  complicate  the  opera- 
tion. Locate  the  inner  edge  of  the  biceps,  which  is  the 
guide.  Make  an  incision  three  inches  long  in  the  line  of 
the  artery.  Incise  the  skin  and  fascia,  flex  the  elbow  slightly, 
retract  the  biceps  outward,  feel  for  the  artery,  open  its 
sheath,  separate  its  venae  comites,  and,  having  located  the 
median  nerve,  pass  the  ligature  from  it.  In  the  middle  of 
the  arm  the  nerve  is  in  front  of  or  behind  the  vessel,  above 
the  middle  it  is  external,  and  below  the  middle  internal. 
High  up  the  arm  the  inner  edge  of  the  coraco-brachialis 
is  the  guide,  rather  than  the  biceps,  and  at  this  point  the 
basilic  vein  perforates  the  deep  fascia  and  runs  along  to  the 
inner  side  of  the  artery ;  hence,  high  up,  the  artery  has  three 
companion  veins,  and  there  is  seen  the  ulnar  nerve  to  the 
inside  of  the  artery. 

Axillary  Artery. — To  determine  the  line  of  the  axillary 
artery,  place  the  arm  at  right  angles  to  the  body  and  lay 
down  a  line  from  the  middle  of  the  clavicle  to  the  humerus 
near  the  inner  border  of  the  coraco-brachialis.  The  line  of 
the  third  portion  can  easily  be  approximated  by  projecting 
the  line  of  the  brachial   upward. 

Anatomy  (PI.  4,  Fig.  3  ;  PL  5,  Fig.  i). — The  axillary  artery 
is  the  continuation  of  the  subclavian,  and  runs  from  the 
lower  margin  of  the  first  rib  to  the  inferior  border  of  the 
teres  major  muscle.  It  is  divided  into  three  portions  by 
the  pectoralis  minor  muscle.  The  first  portion  is  above,  the 
second  portion  is  behind,  and  the  third  portion  is  below,  the 
pectoralis  minor.  The  position  of  the  artery  varies  with 
the  position  of  the  limb.  When  the  arm  is  parallel  with  the 
body  the  artery  is  far  from  the  surface  and  forms  a  curve 


DISEASES  AND  INJURIES   OF  HEART  AND    VESSELS.     2/5 

whose  convexity  is  upward  and  outward.  When  the  arm  is 
at  right  angles  to  the  body  the  vessel  is  nearer  the  surface 
and  straight.  When  the  arm  is  raised  above  a  right  angle 
the  artery  comes  near  the  surface  and  forms  a  curve  with 
the  convexity  downward. 

The  first  portion  of  the  axillary  artery  is  occasionally 
ligated.  It  lies  upon  the  first  intercostal  muscle  and  the 
first  serration  of  the  great  serratus  muscle,  and  has  behind 
it  the  posterior  thoracic  nerve ;  on  the  outer  side  of  the 
artery  is  the  brachial  plexus  ;  on  its  inner  side  is  the  axillary 
vein  ;  in  front  of  it  are  the  clavicle,  the  great  pectoral  muscle, 
the  subclavius  muscle,  the  costo-coracoid  membrane,  the 
cephalic  and  acromio-thoracic  veins,  and  the  external  anterior 
thoracic  nerve.  The  branches  of  the  first  part  of  the  axillary 
artefy  are  the  superior  thoracic  and  the  acromio-thoracic. 
The  brachial  plexus  is  external  and  posterior.  The  second 
part  of  the  artery  is  not  ligated.  The  third  part  is  covered 
in  front,  above,  by  the  great  pectoral,  but  is  covered  below 
by  skin  and  fascia ;  behind,  it  has  the  tendon  of  the  sub- 
scapularis,  the  latissimus  dorsi,  and  the  teres  major;  the 
coraco-brachialis  is  on  the  outer  side ;  the  axillary  vein  is 
on  the  inner  side.  It  is  important  to  remember  that  there 
may  be  three  veins,  one  external  and  two  internal.  The 
axillary  vein  is  formed  by  the  venae  comites  of  the  brachial 
artery  joining,  and  this  new  vein  effecting  a  junction  with 
the  basilic  vein.  The  median  nerve  lies  upon  the  axillary 
artery  in  the  upper  part  of  the  third  portion  of  the  vessel's 
course,  and  passes  to  the  outer  side.  The  musculo-cutane- 
ous  nerve  is  external,  but  it  is  only  seen  high  up ;  the  ulnar 
nerve  is  internal ;  the  lesser  internal  and  the  internal  cutaneous 
nerves  are  internal ;  the  musculo-spiral  and  the  circumflex 
nerves  arc  behind.  The  branches  of  the  third  portion  of 
the  axillary  artery  are  the  subscapular  and  the  anterior  and 
posterior  circumflex. 


2/6  A    MANUAL    OF  SURGERY. 

Operations  :  Ligation  of  tlic  TJiird  Portion  (PI.  4,  Fig,  4). — 
The  position  in  this  operation  is  supine  with  the  shoulders 
raised  and  the  arm  abducted  to  a  right  angle.  The  surgeon 
stands  between  the  patient's  arm  and  side.  An  incision  is 
made  three  inches  in  length.  It  begins  at  the  junction  of  the 
anterior  and  middle  thirds  of  the  outlet  of  the  axilla  and 
curves  downward  along  the  inner  margin  of  the  coraco- 
brachialis  muscle,  which  is  the  guide.  Incise  the  integu- 
ments and  fascia,  find  the  coraco-brachialis  muscle,  and  draw 
it  outward.  The  vein  or  veins  will  be  prominent  and  may- 
overlie  the  vessel.  Feel  for  the  pulsations  of  the  artery,  find 
the  median  nerve  and  draw  it  outward,  draw  the  internal 
cutaneous  nerve  inward,  clear  the  artery  from  the  venae 
comites,  and  pass  the  ligature  from  within  outward.  Apply 
the  ligature  well  below  the  circumflex  branches. 

Ligation  of  the  First  Part. — This  operation  (PI.  5,  Fig.  2) 
was  first  performed  in  1 8 1 5  by  Chamberlaine  of  Jamaica.  The 
position  is  supine,  the  upper  part  of  the  body  being  raised, 
a  sand-pillow  being  placed  between  the  scapulae  to  ensure 
carrying  back  of  the  point  of  the  shoulder,  and  the  arm 
being  brought  down  along  the  side.  In  operating  on  the 
left  side  the  surgeon  stands  on  the  outer  side  of  the  left  arm; 
in  operating  on  the  right  side  he  stands  to  the  right  of  the 
subject's  head  and  leans  over  his  shoulder.  The  incision, 
which  is  slightly  curved  downward,  begins  external  to  the 
sterno-clavicular  joint  and  ends  external  to  the  coracoid 
process.  The  incision  is  half  an  inch  below  the  clavicle. 
Incise  skin,  platysma  myoides  muscle,  superficial  nerves,  and 
deep  fascia.  In  the  outer  angle  of  the  wound  watch  out  for 
the  acromio-thoracic  artery  and  the  cephalic  vein.  Incise  the 
pectoralis  major;  find  the  pectoralis  minor  and  draw  it 
down;  open  the  costo- coracoid  membrane  by  a  vertical  in- 
cision near  the  coracoid  process.  The  cephalic  vein  points 
out  the  situation  of  the  axillary  vein.     Find  the    brachial 


DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS.     277 

plexus,  feel  for  the  artery  internal  to  it,  clear  the  vessel, 
draw  the  vein  internally,  and  pass  the  needle  from  within 
outward.  This  avoids  the  dangerous  neighbor,  which  is 
the  axillary  vein.  This  operation  is  difficult,  dangerous, 
and  unusual,  and  in  its  performance  the  axillary  vein,  which 
has  a  close  attachment  to  the  costo-coracoid  membrane,  is 
apt  to  be  torn. 

Subclavian  Artery. — There  is  no  line  for  this  vessel. 

Anatomy  (PL  5,  Fig.  i). — The  subclavian  artery  oi  the 
right  side  arises  from  the  innominate ;  of  the  left  side,  from 
the  arch  of  the  aorta.  The  subclavian  is  divided  into  three 
parts.  The  first  part  runs  from  the  origin  of  the  vessel  to  the 
inner  border  of  the  scalenus  anticus  muscle;  the  second  part 
lies  behind  the  scalenus  anticus  muscle ;  and  the  third  part 
runs  from  the  outer  edge  of  the  muscle  to  the  lower  border 
of  the  first  rib. 

At  the  present  day  the  first  and  second  portions  are  not 
ligated.  The  third  portion  is  contained  in  the  subclavian 
triangle  (Fig.  46),  and  is  superficial.  It  rises,  as  a  rule,  to  half 
an  inch  above  the  clavicle.  The  subclavian  vein  is  below  the 
artery,  being  separated  from  it  by  the  scalenus  anticus 
muscle.  The  brachial  plexus  is  above  and  external  to  the 
artery.  The  vessel  rests  upon  the  first  rib,  and  behind  it  is 
the  scalenus  medius  muscle.  The  suprascapular  and  trans- 
versalis  colli  arteries  and  veins  and  branches  of  the  cervical 
plexus  lie  in  front  of  the  artery,  and  the  external  jugular 
vein  crosses  it  at  its  inner  side.  The  third  portion  gives  off 
no  branches. 

Ligation  of  tlic  TJiird  Part. — This  operation  (PI.  5,  Fig.  2) 
was  first  successfully  performed  in  18 17  by  Post  of  New 
York.  The  position  is  as  follows  :  place  the  patient  upon 
his  back,  raise  the  shoulders,  extend  and  turn  the  head 
toward  the-  opposite  side,  pull  down  the  arm,  and  hold  it 
by  pushing  the  forearm  under  the  patient's  back  (Treves). 


278  A   MANUAL    OF  SURGERY. 

This  pulls  down  the  clavicle,  thus  increasing  the  size  of  the 
subclavian  triangle.  The  operator  stands  facing  the  shoulder, 
with  his  back  toward  the  patient's  feet.  Draw  the  skin  over 
the  subclavian  triangle,  half  an  inch  above  the  clavicle,  down 
upon  this  bone,  and  incise.  This  manoeuvre  avoids  the  exter- 
nal jugular  vein  and  gives  an  incision  half  an  inch  above  the 
collar-bone.  The  incision  reaches  from  the  anterior  edge  of 
the  trapezius  to  the  posterior  border  of  the  sterno-cleido  mas- 
toid (Fig.  46),  and  is  about  three  inches  long.  By  this  in- 
cision are  divided  the  skin,  the  superficial  fascia,  the  platysma 
myoides,  the  vein  running  from  the  cephalic  to  the  external 
jugular,  and  some  superficial  nerves.  Open  the  deep  fascia. 
Draw  the  external  jugular  vein  into  the  outer  angle  of  the 
wound,  and  do  not  divide  it  unnecessarily ;  if  forced  to  do 
so,  tie  the  vein  with  two  ligatures  and  cut  between  them. 
Find  the  outer  edge  of  the  anterior  scalene  muscle,  and  run 
the  finger  down  along  it  to  the  tubercle  on  the  first  rib. 
Draw  up  the  posterior  belly  of  the  omo-hyoid  muscle. 
With  the  finger  on  the  tubercle  recall  the  fact  that  the  vein 
is  in  front  of  the  finger  and  the  artery  is  behind  it,  and  that 
the  subclavian  vein  is  on  a  lower  plane  than  the  artery.  The 
artery  is  felt  beating  as  it  lies  upon  the  rib.  Clear  the  artery 
and  expose  the  lower  cord  of  the  brachial  plexus.  Guard  the 
vein  with  the  finger  and  pass  the  needle  from  above  down- 
ward, as  the  plexus,  which  is  in  more  danger  than  the  vein, 
is  to  be  avoided.  In  this  operation  never  cut  the  transversa- 
lis  colli  or  suprascapular  arteries,  as  they  are  necessary  to  the 
future  anastomotic  circulation.  If  the  field  of  operation  is 
too  small,  incise  the  trapezius  or  sterno-cleido-mastoid  or 
both. 

Region  of  the  Neck. — Anatomy. — The  side  of  the  neck  is 
that  space  between  the  median  line  in  front  and  the  anterior 
edge  of  the  trapezius  behind,  which  space  is  limited  below 
by  the  clavicle  and  above  by  the  body  of  the  jaw  and  an 


DISEASES  AND  INJVRIES   OF  HEART  AND    VESSELS.     279 


Lower  Jaw. 


imaginary  line  running  from  the  angle  of  the  jaw  to  the  mas- 
toid process.  The  sterno-cleido-mastoid  muscle  divides  this 
space  into  an  anterior  and  a  pos- 
terior triangle,  and  each  of  the 
triangles  is  subdivided  by  other 
structures,  the  anterior  into  three 
spaces  and  the  posterior  into  two 
(Fig.  46). 

Anterior  Triangle. — The  anterior 
triangle  is  bounded  in  front  by  the 
median  line  of  the  neck,  behind  by 
the  anterior  margin  of  the  sterno- 
cleido-mastoid,  and  above  by  the 

body    of    the   lower    jaw   and   an     ^  ciavicie.  d 

imas^inary  line  from  the  anHe  of      Fig.  46.— The  Triangles  of  the 

_  ^  Neck,  right-sided  view  (after  Keen)  : 

the      jaw     to      the      mastoid      process,  i.    submaxillary  triangle;  2.  triangle 

•'  ^  of  election,    or   superior   carotid    tn- 

This   space   is   subdivided   into   three  angle;  3.  Triangle  of  necessity,  or  in- 

i  fenor  carotid    triangle  ;    4.    Occipital 

smaller  triangles,  namely,  the  in-   ^"^"^^^ '  5-  Subclavian  triangle. 
ferior  carotid,  the  superior  carotid,  and  the  submaxillary. 

TJie  inferior  carotid  triangle  is  called  the  "  triangle  of 
necessity,"  because  the  common  carotid  in  it  is  ligated, 
not  from  choice,  but  through  force  of  necessity.  It  is 
bounded  in  front  by  the  median  line,  above  by  the  anterior 
belly  of  the  omo-hyoid,  and  below  by  the  anterior  edge  of 
the  sterno-mastoid.  The  floor  of  this  triangle  is  composed 
of  the  longus  colli,  the  scalenus  anticus,  and  the  rectus  capitis 
anticus  major  muscles. 

The  superior  carotid  triangle  is  known  as  the  "  triangle  of 
election,"  because,  whenever  possible,  it  is  elected  to  tie  the 
carotid  in  this  situation.  In  this  region  the  carotid  is  super- 
ficial, and  there  can  be  tied  either  the  external,  the  internal, 
or  the  common  carotid,  as  may  be  desired.  The  triangle  is 
bounded  behind  by  the  anterior  edge  of  the  sterno-mastoid, 
above  by  the  posterior  belly  of  the  digastric,  and  below  by 


280  A    MANUAL    OF  SURGERY. 

the  anterior  belly  of  the  omo-hyoid.  Its  floor  is  composed 
of  the  inferior  and  middle  constrictors  of  the  pharynx  and 
the  thyro-hyoid  and  hyoglossus  muscles. 

The  submaxillary  triangle  is  bounded  above  by  the  body 
of  the  jaw  and  an  imaginary  line  from  the  angle  of  the  jaw 
to  the  mastoid  process,  behind  by  the  posterior  belly  of  the 
digastric  and  the  stylo-hyoid  muscle,  and  in  front  by  the 
middle  line  of  the  neck.  Its  floor  is  composed  of  the 
digastric,  mylo-hyoid,  and  hyoglossus   muscles. 

The  posterior  tria?igle  is  bounded  in  front  by  the  posterior 
border  of  the  sterno-mastoid,  behind  by  the  anterior  edge  of 
the  trapezius,  and  below  by  the  clavicle.  The  posterior  belly 
of  the  omo-hyoid  subdivides  it  into  two  smaller  spaces,  the 
occipital  and  subclavian  triangles. 

The  subclavian  triajigle  is  bounded  above  by  the  posterior 
belly  of  the  omo-hyoid,  below  by  the  clavicle,  and  in  front 
by  the  posterior  border  of  the  sterno-mastoid.  Its  floor  is 
formed  by  the  first  rib  and  the  first  serration  of  the  serratus 
magnus  muscle. 

The  occipital  triangle  is  bounded  in  front  by  the  posterior 
edge  of  the  sterno-mastoid,  behind  by  the  anterior  border 
of  the  trapezius,  and  below  by  the  posterior  belly  of  the 
omo-hyoid  muscle. 

Common  Carotid  Artery. — The  line  of  the  common 
carotid  artery  is  from  the  sterno-clavicular  articulation  to 
midway  between  the  angle  of  the  jaw  and  the  mastoid  pro- 
cess, the  head  being  turned  toward  the  opposite  side. 

Anatomy  (PL  5,  Figs,  i,  3). — The  right  common  carotid 
arises  from  the  innominate  opposite  the  sterno-clavicular 
joint;  the  left  common  carotid  arises  from  the  arch  of 
the  aorta.  In  the  neck  the  two  carotids  possess  identical 
relations.  The  common  carotid  runs  upward  and  outward 
from  behind  the  sterno-clavicular  articulation  to  a  level 
with  the  upper  border  of  the   thyroid   cartilage,  at  which 


DISEASES  AND  INJURIES   OF  HEART  AND    VESSELS.     28 1 

point  it  divides  into  the  external  and  internal  carotids.  The 
common  carotid  is  contained  in  a  sheath  from  the  cervical 
fascia,  which  sheath  also  holds,  though  in  separate  compart- 
ments, the  internal  jugular  vein  on  the  outer  side  of  the 
artery  and  the  pneumogastric  nerve  between  the  vein  and 
artery  and  behind  them.  The  anterior  edge  of  the  sterno- 
mastoid  muscle  lies  over  the  artery  and  is  a  guide.  Low  in 
the  neck  the  common  carotid  is  deep,  being  covered  by  skin, 
superficial  fascia,  platysma,  deep  fascia,  and  the  sterno-mas- 
toid,  sterno-hyoid,  and  sterno-thyroid  muscles.  Above  the 
omo-hyoid  the  vessel  is  more  superficial,  being  covered  by 
the  skin,  superficial  fascia,  platysma,  deep  fascia,  and  the  an- 
terior edge  of  the  sterno-mastoid.  Upon  the  sheath  (occa- 
sionally within  it),  above  the  crossing  of  the  omo-hyoid 
muscle,  lies  the  descendens  noni  nerve — the  descending 
branch  of  the  ninth  pair  of  Willis  (the  hypoglossal).  This 
nerve  is  a  valuable  guide  to  the  sheath  in  the  triangle  of 
election. 

TJie  stej'uo-viastoid  branch  of  the  superior  thyroid  artery 
crosses  the  carotid  a  little  below  its  bifurcation,  and  the 
superior  thyroid  veins  cross  it  in  this  region ;  the  middle 
thyroid  vein  crosses  the  middle  of  the  line  of  the  artery, 
and  the  anterior  jugular  vein  crosses  low  down.  The  carotid 
rests  upon  the  longus  colli  and  rectus  capitis  anticus  major 
muscles,  the  sympathetic  nerve  lying  between  the  last-named 
muscle  and  the  vessel,  outside  the  carotid  sheath.  The 
recurrent  laryngeal  nerve  passes  behind  the  carotid  below 
the  omo-hyoid  muscle,  and  the  inferior  thyroid  artery  passes 
behind  the  carotid  just  above  the  omo-hyoid  muscle.  The 
carotid  is  in  relation  internally  with  the  trachea,  thyroid 
gland,  larynx,  and  pharynx.  On  its  outer  side  are  the 
pneumogastric  nerve  (which  is  on  a  posterior  plane)  and 
the  jugular  vein.  On  the  left-hand  side,  low  down  in  the 
neck,  the  jugular  vein  often  lies  in  front,  or  partly  in  front, 


282  A   MANUAL    OF  SURGERY. 

of  the  artery.  Ligation  of  the  common  carotid  was  first 
successfully  performed  in   i8o6  by  Sir  Astley  Cooper. 

Ligaticvi  in  the  Triangle  of  Necessity. — In  this  operation 
the  position  is  supine  with  the  shoulders  raised,  a  sand- 
pillow  under  the  neck,  and  the  head  turned  to  the  opposite 
side  with  the  chin  raised.  The  operator  stands  upon  the 
side  operated  upon.  The  incision,  three  inches  long,  at  an 
angle  of  five  degrees  to  the  arterial  line,  runs  from  the  level 
of  the  cricoid  cartilage  downward  and  inward  toward  the 
sterno-clavicular  joint,  following  the  inner  border  of  the 
sterno-cleido-mastoid.  Avoid  cutting  the  external  jugular 
vein,  the  course  of  which  should  be  outlined  before  making 
the  incision.  Open  the  deep  fascia,  draw  the  sterno-cleido- 
mastoid  outward,  retract  the  sterno-hyoid  and  sterno-thyroid 
muscles  inward,  and  feel  for  the  carotid  tubercle  of  Chassaignac. 
This  tubercle  is  the  costal  process  of  the  sixth  cervical  verte- 
bra, and  lies  directly  under  the  artery.  The  tubercle  is  found 
about  the  point  at  which  the  omo-hyoid  crosses  the  carotid. 
When  the  tubercle  is  found  we  know  the  situation  of  the 
artery,  and  that  the  triangle  of  necessity  is  below,  and  the 
triangle  of  election  above,  the  finger.  Pull  the  omo-hyoid 
muscle  upward.  Open  the  sheath  on  its  inner  side,  clear 
it,  and  pass  the  needle  from  without  inward  to  avoid  the 
internal  jugular  vein,  remembering  that  the  pneumogastric 
nerve  is  in  the  same  sheath  as  the  artery  and  vein,  posterior 
and  external  to  the  artery.  In  this  operation  the  inferior 
thyroid  veins  are  much  in  the  way,  the  anterior  jugular 
vein  crosses  low  down,  and  on  the  left  side,  at  the  root  of 
the  neck,  the  internal  jugular  vein  may  be  in  front  of  the 
carotid  artery.  If  the  incision  is  not  sufficiently  wide,  incise 
the  sterno-cleido-mastoid  or  the  sterno-hyoid  and  thyroid. 
In  the  triangle  of  necessity  the  descendens  noni  nerve  does 
not  serve  as  a  guide  to  the  sheath. 

Ligation  in  the   Triangle  of  Election. —  In   this  operation 


DISEASES  AND  INJURIES   OF  HEART  AND    VESSELS.     283 

the  position  is  the  same  as  in  the  preceding  one.  An  incis- 
ion, three  inches  in  length,  is  made  along  the  anterior  edge 
of  the  sterno-mastoid  in  the  line  of  the  artery,  the  middle 
of  this  incision  being  opposite  the  cricoid  cartilage.  In  cut- 
ting the  superficial  fascia,  avoid  the  external  jugular  vein. 
Open  the  deep  fascia,  retract  the  sterno-cleido-mastoid  out- 
ward, feel  for  the  carotid  tubercle,  draw  the  omo-hyoid  down- 
ward,-find  the  descendens  noni  nerve  upon  the  sheath,  open 
the  sheath  at  its  inner  side,  and  pass  the  needle  from  without 
inward.  This  incision  permits  ligation  of  either  the  superior 
thyroid  or  the  external,  internal,  or  common  carotid,  and  if 
it  be  extended  up  a  little  there  can  be  tied  through  it  the 
lingual,  and  even  the  facial  and  occipital,  arteries. 

External  Carotid  Artery. — The  line  of  the  external  carotid 
artery  is  the  upper  portion  of  the  common  carotid  line. 

Anatomy. — The  external  carotid  artery,  which  is  one  of  the 
terminal  branches  of  the  common  carotid,  arises  on  a  level 
with  the  upper  border  of  the  thyroid  cartilage  and  runs  to 
the  level  of  the  neck  of  the  condyle  of  the  lower  jaw.  At 
its  point  of  origin  it  is  covered  only  by  skin,  platysma  and 
fascia,  and  the  edge  of  the  sterno-mastoid,  but  as  it  ascends 
it  passes  beneath  the  digastric  and  stylo-hyoid  muscles  and 
into  the  parotid  gland.  The  glosso-pharyngeal  nerve,  sty- 
loid process,  and  stylo-pharyngeus  mauscle  lie  between  the 
external  and  internal  carotid  arteries.  The  hypoglossal 
nerve  crosses  the  vessel  just  below  the  digastric  muscle, 
and  the  facial  and  lingual  veins  cross  it  a  little  below  the 
nerve.  The  first  branch  is  the  superior  thyroid,  which  arises 
from  the  very  beginning  of  the  trunk.  The  lingual  arises  on 
a  level  with  the  greater  cornu  of  the  hyoid  bone.  The 
facial  and  occipital  take  origin  above  the  lingual.  Each  of 
them  can  be  ligated  through  the  incision  of  this  operation. 

Operation. — The  position  is  the  same  as  that  for  the  com- 
mon carotid.     The  spot  of  election  is  between  the  superior 


284  A   MANUAL    OF  SURGERY. 

thyroid  and  the  lingual.  Make  an  incision  three  inches  long 
in  the  arterial  line,  from  near  the  angle  of  the  jaw  to  oppo- 
site the  middle  of  the  thyroid  cartilage,  cut  through  skin, 
platysma,  and  deep  fascia,  and  retract  the  sterno-cleido  mas- 
toid outward.  Look  for  the  digastric  muscle,  find  the  hypo- 
glossal nerve,  and  feel  for  the  greater  cornu  of  the  hyoid 
bone.  Open  the  sheath  a  little  below  the  hyoid  cornu  and 
pass  the  needle  from  without  inward,  being  certain  not  to 
include  in  the  ligature  the  superior  laryngeal  nerve. 

Internal  Carotid  Artery. — The  line  of  the  internal  carotid 
is  parallel  with  and  half  an  inch  external  to  the  line  for  the 
external  carotid. 

Anatoviy. — The  internal  carotid  artery,  the  other  terminal 
branch  of  the  common  carotid,  arises  on  a  level  with  the 
upper  border  of  the  thyroid  cartilage  and  enters  the  carotid 
canal.  The  first  inch  of  the  artery  is  the  only  point  where  a 
ligature  is  ever  applied,  this  point  being  covered  only  by  skin, 
platysma,  fascia,  and  sterno-mastoid  ;  higher  up  it  is  more 
deeply  placed.  It  rests  upon  the  vertebrae  and  the  rectus 
capitis  anticus  major  muscle.  The  internal  jugular  vein  is 
in  the  same  sheath  and  external  to  the  artery ;  the  pneumo- 
gastric  is  in  the  same  sheath,  between  the  artery  and  the  vein, 
but  posterior  to  both.  The  superior  cervical  ganglion  of  the 
sympathetic  lies  behind  the  origin  of  the  internal  carotid, 
and  between  the  ganglion  and  the  artery  is  the  superior 
laryngeal  nerve. 

Operation. — In  this  operation  the  position  is  the  same  as 
in  ligation  of  the  external  carotid.  Incision  as  for  the 
external  carotid,  except  that  it  is  half  an  inch  external. 
The  sterno-cleido-mastoid  is  drawn  outward,  the  external 
carotid  artery  is  found  and  drawn  inward,  the  internal  carotid 
is  found  and  drawn  outward,  and  the  needle  is  passed  from 
without  inward.  The  internal  carotid  is  known  by  its  more 
external  position  and  by  the  fact  that  it  gives  off  no  branches. 


LIGATIONS. 


Plate  6. 


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DISEASES  AND  INJURIES   OF  HEART  AND    VESSELS.     285 

Lingual  Artery. — Anatomy  (PI.  5,  Fig.  3). — The  lingual 
artery  arises  from  the  external  carotid  opposite  the  greater 
cornu  of  the  hyoid  bone,  passes  beneath  the  digastric  and 
stylo-hyoid  muscles,  reaches  the  margin  of  the  hyoglossus, 
passes  under  that  muscle,  and  emerges  from  under  it  to  run 
along  the  under  surface  of  the  tongue.  The  place  of  elec- 
tion for  ligation  is  where  the  artery  is  beneath  the  hyoglossus 
muscle  and  rests  upon  the  genio-glossus.  Its  guide  is  the 
hypoglossal  nerve,  which  lies  upon  the  muscle,  but  at  a 
slightly  higher  level  than  the  artery. 

Operation. — In  this  operation  (PI.  5,  Fig.  4)  the  position 
is  recumbent  with  the  shoulders  raised  and  the  face  turned 
away  from  the  side  to  be  operated  upon.  The  surgeon 
should  stand  upon  the  affected  side.  A  curved  incision  is 
made  from  a  little  external  to  the  symphysis  of  the  lower 
jaw,  downward  and  outward,  to  just  above  the  greater  cornu 
of  the  hyoid  bone,  and  upward  and  outward  to  just  in  front 
of  the  facial  artery  at  the  lower  edge  of  the  lower  jaw. 
Incise  the  skin,  the  superficial  fascia  and  platysma,  and  the 
deep  fascia.  Clear  the  submaxillary  gland  and  retract  it 
well  upward.  Divide  the  fascia  below  the  gland  by  a  trans- 
verse incision.  Find  the  posterior  edge  of  the  mylo-hyoid 
and  the  bellies  of  the  digastric.  Catch  one  of  the  digastric 
tendons  and  have  it  hooked  down  and  out  (Treves).  Clear 
the  hyoglossus  muscle  with  a  director ;  find  the  hypoglossal 
nerve  and  ranine  vein  and  draw  them  a  little  upward.  Divide 
the  hyoglossus  muscle  transversely  a  little  above  the  hyoid 
bone  and  below  the  level  of  the  hypoglossal  nerve,  find  the 
artery,  and  pass  the  needle  from  above  downward. 

Dorsalis  Pedis  Artery. — The  li}ic  of  the  dorsalis  pedis 
artery  is  from  the  middle  of  the  front  of  the  ankle-joint  to 
the  middle  of  the  base  of  the  first  interosseous  space. 

Anatomy  (PL  6,  Fig.  i). — The  dorsalis  pedis  is  a  continua- 
tion of  the  anterior  tibial  artery,  and  it  runs  from  the  bend  of 


286  A   MANUAL    OF  SURGERY. 

the  ankle  to  the  proximal  extremity  of  the  first  interosseous 
space,  where  it  divides  into  the  dorsalis  hallucis  and  the 
communicating  arteries.  The  artery  rests,  from  above  down- 
ward, upon  the  astragalus,  scaphoid,  and  internal  cuneiform 
bones,  and  at  its  point  of  bifurcation  lies  between  the  heads 
of  the  first  dorsal  interosseous  muscle.  It  may  lie  in  some 
persons  a  little  external  to  this  course.  It  is  held  upon  the 
bones  by  a  distinct  layer  derived  from  the  deep  fascia.  This 
artery  is  covered  by  skin,  by  superficial  and  deep  fascia, 
and  by  the  annular  ligament  above,  and  is  sometimes  partly 
overlaid  by  the  extensor  proprius  pollicis  muscle,  and  is 
crossed,  just  before  its  bifurcation,  by  the  innermost  tendon 
of  the  extensor  brevis  muscle.  The  inner  tendon  of  the 
extensor  communis  digitorum  is  to  the  outer  side  of  the 
vessel ;  the  tendon  of  the  extensor  proprius  pollicis  is  to  the 
inner  side  and  is  a  guide.  The  artery  is  ligated  in  the  dorsal 
triangle  of  the  foot — a  space  which  is  bounded  above  by  the 
lower  edge  of  the  annular  ligament,  externally  by  the  inner 
tendon  of  the  extensor  brevis,  and  internally  by  the  tendon 
of  the  extensor  proprius  pollicis.  The  artery  has  venae 
comites ;  the  anterior  tibial  nerve  lies,  as  a  rule,  to  its  inner 
side,  and  the  inner  division  of  the  musculo-cutaneous  nerve 
to  its  outer  side  in  the  superficial  parts.  The  anterior  tibial 
nerve  may  be  found  upon  the  artery  or  to  its  outer  side. 

Operation  (PI.  6,  Fig.  2). — In  this  operation  the  position  of 
the  patient  is  supine  with  the  legs  and  feet  extended.  The 
surgeon  stands  below  the  extremity,  cutting  from  above 
downward.  Make  an  incision  two  inches  in  length  along  the 
arterial  line,  beginning  opposite  the  lower  edge  of  the  annular 
ligament  and  running  along  by  the  tendon  of  the  extensor 
proprius  pollicis  ;  cut  through  the  skin,  superficial  fascia,  and 
deep  fascia ;  have  the  toes  extended ;  retract  the  tendon  of 
the  extensor  proprius  pollicis  inward  and  the  tendon  of  the 
extensor  communis  outward ;  clear  the  artery,  find  the  nerve. 


DISEASES  AND  INJURIES   OF  HEART  AND    VESSELS.     287 

try  and  separate  the  venae  comites,  and  pass  the  needle  from 
the  nerve. 

Anterior  Tibial  Artery. — To  locate  the  line  of  the  anterior 
tibial,  find  a  point  midway  between  the  head  of  the  fibula  and 
the  tuberosity  of  the  tibia,  drop  one  inch,  and  draw  a  line 
from  the  second  point  to  the  middle  of  the  front  of  the 
ankle-joint. 

Anatomy. — The  anterior  tibial  artery  is  one  of  the  terminal 
branches  of  the  popliteal ;  it  arises  opposite  the  lower  border 
of  the  popliteus  muscle,  passes  forward  between  the  two 
heads  of  the  posterior  tibial  muscle,  comes  to  the  front  of 
the  leg  through  an  opening  in  the  interosseous  membrane, 
and  runs  down  to  the  middle  of  the  front  of  the  ankle-joint. 
In  the  upper  two-thirds  of  its  course  it  rests  upon  the  inter- 
osseous membrane,  to  which  it  is  fastened  by  firm  fascia ;  in 
the  lower  third  it  lies  first  upon  the  front  of  the  tibia  and 
then  upon  the  anterior  ligament  of  the  ankle-joint.  For 
its  upper  two-thirds  the  artery  has  the  tibialis  anticus  muscle 
just  internal  to  it;  at  the  junction  of  the  middle  and  louder 
thirds  the  extensor  proprius  poUicis  comes  from  the  outside 
and  lies  either  upon  the  artery  or  to  its  inner  side  for  the 
rest  of  its  course.  Externally  in  its  upper  third  is  the  ex- 
tensor communis  digitorum,  in  the  middle  third  is  the 
extensor  proprius  pollicis ;  in  the  lower  third,  the  proprius 
pollicis  having  crossed,  the  extensor  communis  again.  The 
artery  is  covered  by  skin  and  by  superficial  and  deep  fascia. 
In  its  upper  third  it  is  deeply  set  between  the  muscles ;  in 
its  middle  third  it  is  less  overlaid  by  muscle ;  in  its  lower 
third  it  is  superficial  except  where  it  is  crossed  by  the 
extensor  proprius  and  where  it  is  covered  by  the  annular 
ligament.  The  artery  has  venae  comites.  In  the  lower  three- 
fourths  of  its  course  it  is  accompanied  by  the  anterior  tibial 
nerve,  which  in  its  course  in  the  upper  third  of  the  leg  is 
external  to  the  artery ;  in  the  middle  third  it  is  external  and 


288  A   MANUAL    OF  SURGERY. 

a  little  in  front  of  the  artery;  and  in  the  lower  third  it  is  ex- 
ternal to  or  upon  the  artery  (PI.  5,  Fig.  5). 

Operations. — The  ligations  of  the  anterior  tibial  (PL  5, 
Fig.  6)  are  (l)  in  the  lower  third;  (2)  in  the  middle  third; 
and  (3)  in  the  upper  third.  In  all  these  ligations  the  sur- 
geon stands  outside  of  the  extremity,  cutting  from  above 
downward  on  the  right  side  and  from  below  upward  on  the 
left  side. 

Ligation  in  the  Loiver  Third. — This  operation  is  prac- 
tically the  same  as  that  for  the  dorsalis  pedis.  Make  an 
incision  three  inches  long  in  the  line  of  the  artery  and  over 
the  annular  ligament.  This  incision  is  external  to  the  tibi- 
alis anticus  muscle  and  half  an  inch  from  the  outer  border 
of  the  tibia  (Barker).  Divide  the  skin  and  fascia,  retract  the 
tendon  of  the  tibialis  anticus  inward,  and  the  tendon  of  the 
extensor  proprius  pollicis,  along  with  the  tendons  of  the 
extensor  communis,  outward.  Flex  the  ankle-joint  and  clear 
the  artery.  Draw  the  nerve  external  and  pass  the  ligature 
from  without  inward.  In  order  to  recognize  the  muscles  in 
this  as  in  other  ligations,  rely  largely  upon  the  finger  while 
the  muscles  are  being  moved. 

Ligation  in  the  Middle  Third. — In  this  operation  the  pro- 
cedure is  similar  to  the  above.  Remember  that  the  nerve 
lies  upon  the  vessel  and  that  the  extensor  proprius  pollicis 
muscle  is  external.  The  nerve  is  retracted  outward  and  the 
needle  is  passed  from  the  nerve.  A  good  rule  for  detecting 
the  artery  is  to  find  the  outer  edge  of  the  tibia  and  by  this 
locate  the  interosseous  membrane,  and  then,  by  passing  out 
along  this  membrane,  discover  the  artery. 

Ligation  in  the  Upper  Third. — In  this  operation  the  position 
is  the  same  as  in  the  above.  Make  an  incision  three  inches 
long  in  the  arterial  line.  On  opening  the  deep  fascia,  do  not 
rely  on  the  eye  for  finding  the  muscular  interspace,  as  often 
the  latter  cannot  be  seen,  and  neither  a  white  nor  a  yellow 


DISEASES  AND  INJURIES   OF  HEART  AND    VESSELS.     289 

line  is  reliable.  Place  the  index  finger  deep  in  the  wound 
and  have  the  tibialis  anticus  and  extensor  communis  muscles 
successively  rendered  tense  by  an  assistant.  In  opening  the 
interspace,  use  the  handle  of  the  knife.  Relax  the  muscles, 
retract  the  tibialis  anticus  inward,  and  draw  the  extensor 
communis  outward.  Find  the  interosseous  membrane  where 
it  is  attached  to  the  edge  of  the  tibia,  and  the  artery  will  be 
found'  upon  this  membrane,  between  the  tibia  and  the  nerve. 
Clear  the  vessel  and  pass  the  ligature  from  without  inward 
to  avoid  the  nerve. 

Posterior  Tibial  Artery. — The  line  of  the  posterior  tibial 
is  from  the  middle  of  the  popliteal  space  to  a  point  midway 
between  the  tip  of  the  inner  malleolus  and  the  point  of  the 
heel  (PL  6,  Figs.  5,  6). 

Anatomy. — The  posterior  tibial  is  the  larger  of  the  two 
terminal  branches  of  the  popliteal.  It  arises  opposite  the 
lower  border  of  the  popliteus  muscle,  runs  down  between 
the  deep  and  superficial  flexor  muscles  to  midway  between 
the  tip  of  the  malleolus  and  the  point  of  the  heel,  and 
divides  into  the  external  and  internal  plantar  vessels.  In  its 
upper  third  it  is  very  deep  and  midway  between  the  tibia  and 
fibula ;  in  its  middle  third  it  is  less  deep,  having  passed  inward ; 
and  in  its  lower  third  it  is  superficial.  At  the  ankle  the 
artery  is  beneath  the  amnular  ligament.  From  above  down- 
ward the  posterior  tibial  artery  rests  upon  the  posterior  tibial 
muscle,  the  flexor  longus  digitorum  muscle,  the  posterior 
surface  of  the  tibia,  and  the  internal  lateral  ligament  of  the 
ankle-joint.  For  the  first  inch  or  two  of  the  course  of  the 
artery  the  posterior  tibial  nerve  is  internal ;  the  nerve  then 
crosses  to  the  outer  side,  and  remains  on  that  side  through- 
out the  rest  of  its  course.  When  the  knee  is  partly  flexed 
and  the  leg  is  laid  upon  its  outer  surface  the  artery  is 
between  the  operator  and  the  nerve  and  the  nerve  is  between 
the  artery  and  the  table.     Back  of  the  malleolus,  in  the  first 

19 


290  A   MANUAL    OF  SUJ^GERY. 

compartment,  lies  the  posterior  tibial  muscle ;  in  the  next 
compartment  is  the  flexor  longus  digitorum  muscle ;  in  the 
next  are  the  artery  and  nerve ;  and  in  the  most  posterior  is 
the  flexor  longus  pollicis  muscle. 

Operations :  Ligation  back  of  the  Malleolus. — In  this  opera- 
tion the  position  of  the  patient  is  recumbent  with  the  thigh 
abducted  and  the  leg  flexed  and  resting  upon  its  outer  sur- 
face. The  sureeon  stands  to  the  outside.  Make  a  two-inch 
semilunar  incision  corresponding  in  its  curve  to  the  malle- 
olus and  half  an  inch  posterior  to  its  margin.  Cut  down 
to  the  annular  ligament,  incise  it,  and  find  the  artery  and 
venae  comites.  Clear  the  vessel  and  pass  the  needle  from 
behind  forward  (to  avoid  the  nerve,  which  is  here  posterior 
and  external).  Do  not  make  the  preliminary  incision  nearer 
the  malleolus  than  half  an  inch,  as  the  sheath  of  the  tibialis 
posticus  muscle  would  then  surely  be  opened.  In  sewing 
up,  suture  the  ligament  (PI.  6,  Fig.  6). 

Ligation  in  the  Middle  of  the  Leg. — In  this  operation  the 
position  is  the  same  as  in  the  above.  Feel  for  the  inner 
border  of  the  tibia,  and  make  an  incision  four  inches  long 
one  inch  behind  the  border  and  parallel  with  it,  and  extend- 
ing through  skin  and  superficial  and  deep  fascia.  Draw  the 
gastrocnemius  outward.  Incise  the  soleus,  but  not  the  fascia 
beneath  the  soleus  ;  cut  this  fascia,  dropping  the  handle  of 
the  knife  so  that  the  blade  will  be  at  right  angles  with  the 
plane  of  the  tibia.  Clear  the  artery  ;  pass  the  needle  from 
without  inward  (PI.  6,  Fig.  6). 

The  popliteal  artery  is  now  never  ligated  in  continuity ; 
hence  the  methods  that  may  be  used  will  not  be  discussed. 

Femoral  Artery. — The  line  of  the  femoral  artery  is  from 
midway  between  the  anterior  superior  spine  of  the  ilium  and 
the  symphysis  pubis  to  the  adductor  tubercle  on  the  inner 
condyle  of  the  femur,  the  thigh  being  abducted  and  resting 
upon  its  outer  surface  (PI.  6,  Fig.  3). 


DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS.    29 1 

Anatojiiy. — The  femoral  artery  is  the  continuation  of  the 
external  iliac  trunk ;  it  extends  from  the  lower  border  of 
Poupart's  ligament  to  the  opening  in  the  adductor  magnus 
muscle,  and  hence  occupies  the  upper  two-thirds  of  the 
thigh.  The  artery  for  its  first  five  inches  is  superficial,  lying 
in  Scarpa's  triangle,  which  is  bounded  externally  by  the 
sartorius  muscle  and  internally  by  the  adductor  longus,  its 
base  being  Poupart's  ligament  and  its  floor  being  composed 
of  the  psoas,  iliacus,  pectineus,  and  often  the  adductor  brevis. 
The  artery  enters  the  triangle  as  the  common  femoral,  but 
after  a  two-inch  course  it  divides  into  the  profunda,  which 
passes  deeply,  and  the  superficial  femoral.  The  latter  vessel 
is  the  one  alluded  to  in  this  section. 

At  the  base  of  Scarpa's  triangle  the  vein  is  internal,  the 
artery  is  between,  and  the  nerve  is  external  (v.  A.  n.).  At 
the  apex  of  the  triangle  the  vein  is  posterior  and  a  little 
internal.  At  the  apex  of  the  triangle  the  superficial  femoral 
passes  under  the  sartorius  muscle  and  enters  into  Hunter's 
canal,  which  occupies  the  middle  third  of  the  thigh  and 
which  terminates  at  the  opening  in  the  adductor  magnus 
muscle.  Hunter's  canal  is  bounded  externally  by  the  vastus 
internus,  internally  by  the  adductors  longus  and  magnus,  and 
its  roof  is  fascia  which  stretches  from  the  adductor  longus  to 
the  vastus.  In  Hunter's  canal  the  vein  is  behind  the  artery 
above,  but  external  to  it  in  the  lower  part  of  the  canal,  and 
is  firmly  attached  to  the  artery.  There  may  be  two  veins. 
Inside  Hunter's  canal,  but  outside  the  femoral  sheath,  is  the 
long  saphenous  nerve,  which  crosses  the  artery  from  without 
inward. 

A  good  way  to  remember  the  relation  of  the  femoral  vein 
with  the  femoral  artery  is  to  recall  the  fact  that  the  relation 
of  the  vein  to  the  artery  is  always  contrary  to  the  relation 
of  the  sartorius  muscle  with  the  artery :  when  the  sartorius 
muscle  is  external  to  the  artery  the  vein  is  internal,  as  at  the 


292  A   MANUAL    OF  SURGERY. 

base  of  Scarpa's  triangle ;  when  the  sartorius  muscle  is  cross- 
ing in  front  toward  the  inside  of  the  artery  the  vein  is  pass- 
ing at  the  back  to  the  outside,  as  at  the  apex  of  Scarpa's 
triangle  ;  when  the  muscle  is  over  the  artery  the  vein  is  back 
of  it,  as  in  the  upper  third  of  Hunter's  canal ;  and  when  the 
muscle  is  to  the  inside  of  the  artery  the  vein  is  to  the  out- 
side, as  in  the  lower  two-thirds  of  Hunter's  canal.  In  a 
ligation  at  the  apex  of  Scarpa's  triangle  the  inner  edge  of 
the  sartorius  is  the  guide.  In  a  ligation  in  Hunter's  canal 
the  long  saphenous  nerve  is  the  guide. 

Operations :  Ligation  of  the  Superficial  Femoral  at  the  Apex 
of  Scarpa's  Triangle. — In  this  operation  the  position  is  supine 
with  the  thigh  and  leg  a  little  flexed,  the  thigh  abducted, 
everted,  and  rested  upon  its  outer  surface  on  a  pillow  The 
operator  stands  to  the  outside  of  the  leg.  From  a  point  cor- 
responding to  the  middle  of  the  triangle,  and  two  and  a  half 
inches  below  Poupart's  ligament,  make  a  three-inch  incision 
in  the  arterial  line.  Cut  the  skin  and  superficial  fascia.  The 
saphenous  vein  will  not  be  seen  unless  the  incision  is  internal 
to  the  arterial  line ;  if  this  vein  is  seen,  draw  it  inward. 
Open  the  fascia  lata,  find  the  inner  border  of  the  sartorius 
muscle,  and  draw  it  outward.  The  fibres  of  this  muscle  run 
downward  and  inward,  thus  distinguishing  it  from  the  ad- 
ductor longus,  whose  fibres  run  downward  and  outward. 
Open  the  common  sheath  for  the  artery  and  vein,  and  then 
incise  the  individual  arterial  sheath.  Clear  the  artery  and 
pass  the  ligature  from  within  outward  (PI.  6,  Fig.  4). 

Ligation  of  the  Superficial  Femoral  in  Hunter's  Canal. — In 
this  operation  the  position  is  the  same  as  in  the  above. 
Make  a  three-inch  incision  in  the  middle  third,  but  above 
the  middle  of  the  thigh,  parallel  with  the  arterial  line  and 
half  an  inch  internal  to  it  (Barker).  Incise  the  skin  and 
superficial  fascia,  look  out  for  the  internal  saphenous  vein, 
open  the  fascia  lata,  and  find    the   sartorius  and  retract  it 


DISEASES  AND   INJURIES   OF  HEART  AND    VESSELS.     293 

inward,  thus  exposing  the  roof  of  Hunter's  canal,  which  is 
to  be  opened  for  an  inch  or  more.  Within  the  canal  is  seen 
the  long  saphenous  nerve,  usually  upon  the  sheath.  Open 
the  sheath  of  the  artery,  clear  the  vessel,  and  pass  the  needle 
from  without  inward. 

Iliac  Arteries. — The  line  of  the  common  and  external 
iliac  is  from  half  an  inch  below  and  half  an  inch  to  the  left 
of  the  umbilicus  to  midway  between  the  anterior  superior 
spine  of  the  ilium  and  the  pubic  symphysis.  The  upper 
third  of  this  line  represents  the  common  iliac,  and  the  lower 
two-thirds  the  external  iliac  (PL  3,  Fig.  4). 

Anatomy. — The  common  iliac  arteries  arise  from  the  aorta 
opposite  the  left  side  and  lower  border  of  the  fourth  lumbar 
vertebra,  and  extend  to  the  upper  margin  of  the  right  and 
left  sacro-iliac  joints,  where  they  each  bifurcate  into  an 
external  and  an  internal  iliac.  The  common  iliac  arteries  lie 
upon  the  fifth  lumbar  vertebra,  are  covered  with  peritoneum, 
and  are  crossed  by  the  ureters.  In  women  the  ovarian  arteries 
cross  the  common  iliacs.  The  common  iliac  veins  lie  to  the 
right  side  of  their  respective  arteries.  The  right  common  iHac 
artery  has  in  front  of  it,  besides  the  peritoneum  and  ureter  (in 
women  also  the  ovarian  artery),  the  ileum,  branches  of  the 
superior  mesenteric  artery,  and  branches  of  the  sympathetic 
nerve.  The  left  common  iliac  artery  has  in  front  of  it,  in 
addition  to  structures  common  to  both  sides  (ureter,  ovarian 
artery,  sympathetic  branches),  branches  of  the  inferior  mes- 
enteric artery  and  the  sigmoid  flexure  with  its  mesocolon. 
The  internal  iliac  artery  runs  from  the  sacro-iliac  joint  to 
the  upper  margin  of  the  great  sacro-sciatic  foramen.  It  is 
very  rarely  ligated  (only  in  uncontrollable  hemorrhage  from 
the  gluteal  or  sciatic  arteries).  The  external  iliac  runs  from 
the  sacro-iliac  joint  along  the  pelvic  brim,  upon  the  inner  edge 
of  the  psoas  muscle,  to  Poupart's  ligament.  The  external 
iliac  vein  is  internal  to  the  artery.     On  the  right  side,  high 


294  ^^    MANUAL    OF  SURGERY. 

up,  it  passes  behind  the  artery.  The  external  ihac  has  in 
front  of  it  peritoneum  and  subserous  tissue  (Abernethy's 
fascia).  The  ihum  crosses  the  right,  and  the  sigmoid  flexure 
the  left,  external  iliac.  The  genital  branch  of  the  genito- 
crural  nerve  crosses  the  artery  low  down,  and  the  circumflex 
iliac  vein  crosses  it  just  before  it  terminates  in  the  femoral. 
The  spermatic  vessels  and  the  vas  deferens  in  the  male,  the 
ovarian  vessels  in  the  female,  lie  upon  it,  low  down.  Some- 
times the  ureter  crosses  it  high  up.  We  find  the  spermatic 
vessels  in  the  male  and  the  ovarian  in  the  female  lying  for 
a  time  upon  the  inner  side  of  the  artery. 

Ligation  of  the  Iliacs  by  Abdominal  Section. — The  best 
method  for  ligating  either  iliac  is  by  abdominal  section,  pack- 
ing away  the  intestines  with  gauze,  opening  the  peritoneum 
posteriorly,  and  selecting  the  vessel  to  be  tied  and  the  exact 
spot  where  it  is  desired  to  apply  a  ligature  (Hearn  and  other 
operators).  In  ligating  either  common  iliac,  pass  the  needle 
from  right  to  left.  In  ligating  the  external  iliac,  pass  the 
ligature  from  within  outward. 

Ligation  of  tJie  External  Iliac  by  Abernethf  s  Extra-perito- 
neal Method. — In  this  operation  the  position  of  the  patient  is 
recumbent  with  the  thighs  extended  during  the  first  incisions, 
but  in  the  latter  stages  of  the  operation  they  are  flexed  a  little 
to  relax  the  abdominal  structures,  the  operator  standing  to 
the  outside.  The  surgeon  will  find  the  artery  along  the 
psoas  muscle.  Mark  a  point  one  inch  above  and  one  inch 
external  to  the  middle  of  Poupart's  ligament,  and  another 
point  one  inch  above  and  one  inch  internal  to  the  anterior 
superior  iliac  spine  (Barker).  Join  these  two  points  by  a 
curved  incision  four  inches  long  and  convex  downward.  Cut 
the  skin,  the  fat,  the  two  oblique  and  the  transversalis  mus- 
cles ;  open  the  transversalis  fascia,  draw  the  peritoneum 
inward  by  a  broad  retractor,  and  look  for  the  artery  along 
the  pelvic  brim.     The  anterior  crural  nerve  is  seen  internal 


DISEASES  AXD   IXJURIES   OF  BOXES  AXD  JOIXTS.      295 

to  the  artery,  the  vein  is  internal  to  the  artery,  and  the 
genito-crural  nerve  is  upon  the  artery.  Clear  the  artery 
near  its  middle  and  pass  the  ligature  from  within  outward. 
In  Sir  Astley  Cooper's  ligation  the  inguinal  canal  is  laid  open. 


XVIII.   DISEASES  AND  INJURIES  OF  BONES 

AND  JOINTS. 

I.  Diseases  of  the  Bones. 

Atrophy  of  bone  is  a  diminution  in  the  amount  of  bony 
matter  without  change  in  osseous  structure.  It  arises  from 
want  of  use  (as  seen  in  the  wasting  of  the  bone  of  a  stump)  or 
from  pressure  (as  seen  in  the  destruction  of  the  sternum  by 
an  aneurysm  of  the  aorta).  Eccentric  atrophy  is  the  thinning 
of  a  long  bone  from  within,  the  outer  surface  being  un- 
changed— usually  a  senile  change.  Concentric  atrophy  means 
a  thinning  of  the  outer  surface  of  the  shaft,  causing  a  lessened 
diameter.     It  is  usually  linked  with  eccentric  atrophy. 

Hypertrophy  of  bone  may  be  due  to  increased  blood-sup- 
ply (as  is  seen  in  chronic  epiphyseal  inflammation),  the  bone 
growing  much  more  than  does  its  fellow.  It  may  arise  from 
excessive  use  or  from  strain,  as  is  seen  in  the  increased  size 
of  the  fibula  when  the  tibia  is  congenitally  absent  (Bowlby). 

Osteitis,  or  inflammation  of  bone,  may  be  due  to  trauma- 
tism, to  a  constitutional  malady  or  diathesis,  to  the  extension 
of  inflammation  from  some  other  structure,  or  to  infection. 
In  inflammation  of  bone  the  exudation  flows  into  the  Haver- 
sian canals  and  spaces  and  the  canaliculi,  the  corpuscles  of 
the  exudate  and  the  bone-corpuscles  proliferate,  embryonic 
tissue  forms,  the  bone  undergoing  thinning  (rarefaction),  not 
because  of  pressure,  but  because  of  absorption  by  voracious 
leucocytes  and  osteoclasts.  This  process  of  rarefaction 
enlarges  all  the  bony  spaces,  and  by  destroying  septa 
throws  two  or  more  spaces  into  one.     If  the  surface  of  a 


296  A   MANUAL    OF  SURGERY. 

bone  inflames,  the  periosteum  will  more  or  less  be  separated 
by  the  exudation  and  the  bone  will  be  covered  with  little 
pits  or  erosions.  Inflamed  bone  is  so  soft  that  it  can  readily 
be  cut  with  a  knife 

Osteitis  may  terminate  in  resolution  or  it  may  terminate  in 
sclerosis,  the  exudate  being  converted  first  into  fibrous  tissue 
and  next  into  dense  bone  with  only  a  few  small  cancellous 
spaces.  If  the  exudation  is  under  the  periosteum,  the  bone 
will  be  thickened  at  this  point,  bOne  stalactites  marking  the 
point  of  passage  of  the  vessels.  Osteitis  may  terminate  in 
suppuration^  this  condition  being  known  as  "  caries."  In 
strumous  osteitis  caseation  of  the  inflammatory  products  is 
very  apt  to  arise  (strumous  caries).  Acute  osteitis  may  ter- 
minate in  necrosis. 

Symptoms  of  Osteitis  and  Osteo-periostitis. — As  a  chronic 
process  the  symptoms  of  osteitis  are  commonest  in  the  femur. 
Its  history  usually  exhibits  a  record  of  a  cold  or  an  injury. 
Pain  is  severe,  boring  or  aching  in  character,  deep-seated, 
worse  at  night,  and  aggravated  by  a  dependent  position  of  the 
part.  The  symptoms  closely  resemble  those  of  periostitis,  with 
which  disease  it  is  almost  sure  to  be  linked.  Tenderness  ex- 
ists on  percussion,  and  sometimes  on  pressure.  Subperiosteal 
swelling,  fusiform  in  shape,  is  noted ;  cutaneous  oedema  and 
discoloration  are  observed  if  a  superficial  bone  be  involved. 
In  syphilis  atrophic  osteitis  may  attack  the  cranial  bones  and 
produce  softening  or  even  perforation,  or  osteophytic  osteitis 
may  arise,  exostoses  being  formed.  Osteo-periostitis  may  be 
acute  or  chronic,  circumscribed  or  diffused,  and  may  termi- 
nate in  resolution,  organization,  or  suppuration.  It  arises 
from  cold,  blows,  wounds,  strains,  the  spread  of  adjacent 
inflammation,  pyogenic  infection,  syphilis,  rheumatism,  or 
tubercle.  The  symptoms  are  pain  (which  is  worse  at  night 
and  which  is  aggravated  by  motion,  pressure,  and  a  depend- 
ent  position),    swelling,    oedema,  and    discoloration    of  the 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      297 

soft  parts.  Pain  in  the  syphilitic  form  is  not  so  severe  as  in 
other  varieties.  Acute  necrosis  or  diffuse  periostitis,  a  septic 
inflammation  of  bone  and  periosteum,  is  commonest  in  boys 
about  the  age  of  puberty.  It  is  usually  due  to  cold,  a 
specific  fever,  or  injury,  and  generally  affects  the  tibia  or 
femur;  the  symptoms  locally  are  severe;  redness,  swelling, 
and  pain  are  marked  ;  constitutionally,  rigors,  fever,  often 
convulsions.  Necrosis  is  apt  to  result.  Pyaemia  is  common. 
Some  fever  always  exists. 

Treatment  of  Osteitis  and  Osteo-periostitis. — In  syphilitic 
forms  the  treatment  consists  of  rest,  elevation  of  the  part, 
the  local  use  of  iodine  and  mercurial  ointment,  and  bandag- 
ing. Specific  treatment  is  by  the  stomach  or  hypodermati- 
cally.  Operation  is  rarely  justifiable.  In  other  forms,  if  the 
case  be  recent  and  severe,  put  the  patient  to  bed,  place  the 
limb  in  a  splint  and  elevate  it,  apply  leeches,  cold,  and  lead- 
water  and  laudanum,  use  a  bandage,  and  order  salines  and 
iodide  of  potassium.  Morphia  is  used  for  pain.  If  these 
means  fail,  order  counter-irritation  by  iodine  and  blue  oint- 
ment or  blisters,  and  use  heat  locally.  In  severe  cases  take 
a  tenotome  and  slit  the  periosteum  subcutaneously  to  relieve 
tension;  this  procedure  often  instantly  relieves  the  pain. 
Some  cases  demand  a  longitudinal  osteotomy,  which  is  per- 
formed by  taking  a  Hey  saw  and  dividing  the  bone  longitu- 
dinally into  the  medullary  canal.     If  pus  forms,  drain  at  once. 

Diffuse  osteo-periostitis  requires  early  and  free  incisions, 
antiseptics,  drainage,  rest  and  elevation  of  the  limb,  and 
strong  supporting  and  stimulating  treatment.  Amputation 
is  sometimes  demanded,  as  when  the  patient  grows  weaker 
and  weaker  even  after  incision,  and  when  a  joint  is  seriously 
involved.  If  the  necrosis  affects  the  entire  shaft,  which 
separates  from  its  epiphyses,  and  new  bone  has  not  yet 
formed  from  the  periosteum,  make  a  subperiosteal  resection 
of  the  shaft. 


298  A    MANUAL    OF  SURGERY. 

Chronic  periostitis  is  usually  syphilitic.  A  node  is  a 
chronic  inflammation  of  the  deep  periosteal  layers.  Nodes 
occurring  early  in  the  secondary  stage  remain  soft  and  soon 
pass  away,  but  those  occurring  two  years  or  more  after  infec- 
tion are  apt  to  cause  a  bony  deposit.  A  node  may  suppurate, 
leaving  a  sinus  at  the  bottom  of  which  is  a  piece  of  dead 
bone.  Gumma  of  the  periosteum  is  one  form  of  node  which 
is  apt  to  produce  caries  or  necrosis. 

Osteoplastic  periostitis  accompanies  chronic  osteitis  and 
causes  the  deposit  of  new  bone  which  undergoes  sclerosis. 
The  chief  syniptoui  is  aching  pain,  which  is  worse  when 
warm  in  bed  and  is  aggravated  by  damp  and  wet.  A 
swelling  is  found  at  the  seat  of  pain  (often  over  the  tibia, 
ulna,  clavicle,  or  sternum).  The  soft  parts  are  uninflamed 
and  move  freely  unless  softening  or  suppuration  has  occurred. 
Tenderness  is  manifest. 

Treatment. — For  the  nodes  of  early  syphilis  use  mixed 
treatment ;  for  the  nodes  of  late  syphilis  give  mercury  and 
large  advancing  doses  of  iodide  of  potassium.  Blisters,  blue 
ointment,  and  iodine  used  locally,  and  subcutaneous  division 
of  periosteum,  are  of  value.  If  suppuration  occurs,  open 
antiseptically. 

Abscess  of  bone  is  always  chronic,  never  acute.  It  was 
first  described  by  Sir  Benjamin  Brodie,  and  is  often  called 
"  Brodie's  abscess."  It  occurs  in  the  cancellous  structure  of 
the  ends  of  bones — usually  in  the  head  of  the  tibia,  some- 
times in  the  femur  or  humerus.  The  cause  of  bone-abscess  is 
injury  which  induces  osteitis;  bone-rarefaction  forms  a  cavity, 
the  inflammatory  products  suppurate  or  caseate,  and  the 
surrounding  bone  thickens  and  hardens  because  of  growth 
from  the  periosteum.  Pus  is  apt  to  break  into  a  joint,  as  the 
joint-surface  is  not  covered  by  periosteum  and  no  barrier  of 
bone  is  there  formed.  Suppuration  of  bone  may  induce 
necrosis. 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      299 

Syniptoins. — The  symptoms  are  like  those  of  osteo-perios- 
titis,  only  they  are  localized  and  persistent.  These  symp- 
toms are  thickening  of  bone  and  soft  parts,  oedema  and 
discoloration  of  skin,  tenderness,  constant  pain  (subject  to 
violent  exacerbations  and  made  worse  by  motion,  pressure, 
and  a  dependent  position),  and  attack  after  attack  of  syno- 
vitis in  the  nearest  joint.     Fever  and  sweats  may  be  noted. 

Treatment. — In  treating  bone-abscess,  trephine  the  bone  at 
the  point  of  the  greatest  tenderness,  and  if  the  abscess  is 
missed,  follow  the  advice  of  Holmes  and  perforate  the  wall 
of  bone  with  the  trephine,  opening  in  several  directions  to 
discover  the  pus.  If  the  abscess  opens  into  a  joint,  trephine 
the  bone  and  open  and  drain  the  joint. 

Caries  is  a  suppurative  osteitis  with  molecular  osseous  de- 
struction, though  some  surgeons  limit  the  term  to  strumous 
osteitis,  and  others  include  under  it  all  forms  of  osteitis  with 
bone-destruction.  Osteitis  is  apt  to  become  purulent  when 
the  bone  is  exposed  to  the  air,  when  rest  is  not  secured, 
when  the  health  of  the  individual  is  below  normal,  when  a 
foreign  body  such  as  a  bullet  is  in  the  bone,  and  j^vhen  struma 
or  syphilis  exists.  In  this  condition  the  embryonic  tissue 
becomes  pus,  which  is  discharged  from  the  softened  and 
granulating  bone,  and  after  drainage  is  secured  organiza- 
tion, sclerosis,  and  healing  result.  In  these  cases  new  bone 
usually  forms,  and  a  cure  results. 

Strumous  caries,  due  to  caseation  of  the  product  of  an 
osteitis  in  a  scrofulous  subject,  shows  no  tendency  to  self- 
cure,  no  organization  or  sclerosis  taking  place  and  no  new 
bone  being  formed,  the  interior  of  bones,  especially  of  the 
carpus  and  tarsus,  being  entirely  softened  and  destroyed, 
thin  shells  only  being  left. 

Caries  necroiica  is  a  condition  in  which  small  but  visible 
portions  of  soft  and  dead  bone  come  away  in  the  pus ;  caries 
sicca  is  molecular  death  of  bone  without  suppuration. 


300  A   MANUAL    OF  SURGERY. 

The  caseating  masses  in  strumous  caries  contain  the 
tubercle  bacillus.  If  a  strumous  collection  is  evacuated 
and  infection  with  pus  cocci  occurs,  genuine  suppuration 
takes  place,  and  constitutional  infection  means  suppurative 
fever,  and  may  mean  death.  Purulent  osteitis  may  affect 
any  bone,  but  caseous  osteitis  (strumous  caries)  tends  to 
arise  in  cancellous  structure  (heads  of  long  bones,  vertebral 
bodies,  and  bones  of  the  carpus  and  tarsus).  Strumous  oste- 
itis is  apt  to  cause  tubercular  disease  in  an  adjacent  joint. 

Symptoms. — In  the  start  the  symptoms  of  caries  are  usu- 
ally those  of  osteitis,  but  the  first  symptom  noted  may  be 
a  fluctuating  swelling  due  to  pus  or  to  caseated  tubercle. 
After  a  time,  if  not  opened,  the  abscess  breaks,  voids  its  con- 
tents, and  leaves  a  sinus  from  which  runs  a  purulent  matter 
which  after  a  time  becomes  thin,  reddish,  and  irritant  to  the 
skin,  contains  small  portions  of  gritty  bone,  and  has  a  foul 
smell.  The  opening  of  the  sinus  becomes  filled  with 
cedematous  granulations.  A  probe  introduced  to  the  bot- 
tom of  the  sinus  finds  bone  which  on  being  struck  gives 
a  muffled  n^te  rather  than  the  clear,  sharp  note  of  necrosis ; 
the  bone  is  rough,  is  bared,  and  is  so  soft  that  the  probe  can 
usually  be  stuck  into  it. 

Treatment. — If  syphilis  exists,  give  iodide  of  potassium  in 
advancing  doses  and  a  mild  mercurial  course.  If  tubercle 
exists,  give  iodide  of  iron,  arsenic,  cod-liver  oil,  and  nour- 
ishing foods,  and  recommend  a  change  of  air.  Locally,  insist 
on  rest  and  at  once  secure  drainage,  enlarging  the  opening 
if  necessary  and  inserting  a  tube,  and  even  making  additional 
openings ;  syringe  often  with  antiseptic  fluids  and  dress  anti- 
septically.  If  the  case  is  seen  before  the  abscess  has  opened, 
open  it  under  strict  antiseptic  precautions.  When  the  case  is 
found  to  be  chronic  there  arises  the  question  of  operation. 
Incomplete  operations  are  worse  than  useless,  for  they  may 
cause  pyaemia,  and  if  the  case  be  tubercular  may  inaugurate 


DISEASES  AND   INJURIES    OE  BONES  AND  JOINTS.      3OI 

systemic  diffusion  of  the  infection.  If  the  gouge  is  used, 
try  to  remove  all  carious  bone.  The  diseased  bone  is  white, 
crumbles  up,  and  does  not  bleed ;  the  non-carious  bone  is 
pink  and  vascular.  Scrape  away  all  granulations  ;  swab  out 
the  cavity  with  pure  carbolic  acid  and  pack  it  with  iodoform 
gauze.  Instead  of  gouging  away  bone,  there  may  be  used 
the  actual  cautery  or  sulphuric  acid  (Pollock).  In  severe 
cases  excision  is  required,  and  in  some  very  rare  cases 
amputation  may  be  necessary.  Caries  of  the  spine  is  con- 
sidered under  Diseases  of  tJic  Spine  (p.  573). 

Necrosis  is  the  death  of  visible  portions  of  bone  from  cir- 
culatory impediment.  It  is  analogous  to  gangrene.  The 
cause  of  necrosis  is  injury  (such  as  the  tearing  off  of  perios- 
teum) which  deprives  the  bone  of  blood.  Inflammation  of 
the  periosteum  further  lessens  the  nutrition.  Acute  inflam- 
mation in  bone  causes  necrosis,  the  excessive  exudation  in 
the  canals  and  spaces  obliterating  the  blood-vessels  by  pres- 
sure. A  thin  shell  of  bone  only  may  necrose  from  periosteal 
separation,  or  an  entire  shaft  may  die  from  acute  osteo- 
myelitis or  diffuse  infective  periostitis.  A  fragment  of  dead 
bone  is  a  foreign  body ;  the  healthy  bone  adjacent  to  it 
inflames,  softens,  and  granulates,  and  this  line  of  granulations, 
like  the  line  of  demarcation  of  gangrene,  separates  the  dead 
part  from  the  living,  the  white  dead  bone  being  surrounded 
by  the  red  zone  of  granulation  tissue.  A  bit  of  dead  bone 
is  called  a  "  sequestrum,"  and  Nature  tries  to  cast  it  off  A 
superficial  sequestrum  is  known  as  an  "  exfoliation." 

Nature's  method  of  casting  off  a  sequestrum  is  as  follows  : 
Suppuration  takes  place  at  the  line  of  demarcation,  osteitis 
extends  for  a  considerable  distance  around  this  line,  the 
periosteum  shares  in  the  inflammation,  and  new  bone  forms. 
A  cavity  thus  forms  within  by  suppuration,  and  a  box  or 
case  forms  without  by  ossification,  the  now  entirely  loosened 
sequestrum  being  so  encased  that  it  cannot  escape.    The  pus 


302  A   MANUAL    OF  SURGERY. 

finds  its  way  through  the  new  bone,  and  there  is  presented 
the  condition  so  often  seen  by  the  surgeon — namely,  a  case 
of  new  bone  known  as  the  "  involucrum,"  a  cavity  contain- 
ing pus  and  the  dead  fragment  or  sequestrum,  and  a  dis- 
charging sinus  or  "  cloaca."  Nature  may  eventually  get  rid 
of  the  fragment,  but  the  surgeon  should  not  wait. 

When  a  portion  of  the  bone  surrounding  the  medullary 
canal  dies,  the  condition  is  called  "  central  necrosis."  In  some 
rare  cases  necrosis  occurs  without  apparent  suppuration, 
a  painless  swelling  of  bone  simulating  sarcoma.  Mercury 
is  a  cause  of  necrosis.  The  fumes  of  phosphorus  may  cause 
necrosis  of  the  lower  jaw  in  those  with  decayed  teeth. 
Traumatisms  are  usual  causes  of  necrosis,  but  it  may  be 
produced  by  frost-bites  and  burns.  Many  fevers  (measles, 
typhoid,  scarlet  fever,  etc.)  are  followed  by  necrosis.  Syphilis 
and  tubercle  are  occasional  causes. 

Symptoms. — The  symptoms  of  necrosis  are  at  first  those 
of  osteitis.  The  abscess,  when  formed,  opens  of  itself  or  is 
opened  by  the  surgeon,  and  a  sinus  or  sinuses  exist  as  in 
caries.  A  probe  introduced  into  the  sinus  strikes  upon 
hard  bone  with  a  clear,  ringing  note.  In  superficial  necrosis 
the  discharge  is  slight  and  the  probe  shows  the  limitations  of 
the  disease.  In  extensive  necrosis  the  discharge  is  profu.se, 
much  new  bone  forms,  several  sinuses  form  far  apart,  and 
the  probe  must  pass  a  considerable  thickness  of  new  bone 
before  it  finds  the  bit  of  dead  bone.  The  surgeon  should  not 
operate  until  the  dead  bone  is  separated  from  the  living,  until 
a  line  of  demarcation  forms,  and  until  the  sequestrum  is  loose. 
In  youth  dead  bone  loosens  quickly,  but  in  old  age  slowly. 
An  exfoliation  becomes  loose  sooner  than  a  deep  or  a  central 
necrosis.  In  diffuse  periostitis  the  necrosed  shaft  loosens 
quickly.  Necrosed  particles  of  the  upper  extremity  loosen 
more  rapidly  than  those  of  the  lower.     Chilton  states  ^  that 

^  Heath's  Dictionary. 


DISEASES  AND  INJURIES   OF  BONES  AND  JOINTS.      303 

in  the  young-  adult  two  or  three  months  will  be  required  to 
loosen  a  necrosed  fragment  in  the  lower  extremity,  and  from 
six  weeks  to  two  months  in  the  upper  extremity.  A  loose 
sequestrum  may  be  moved  by  the  probe,  and  when  struck 
gives  a  hollow  note.  In  old  cases  of  necrosis  and  caries 
amyloid  disease  may  arise. 

Treatment. — The  treatment  of  necrosis  comprises  free  in- 
cisions' for  drainage,  antiseptic  dressing,  frequent  cleansing, 
rest,  good  food,  stimulants,  and  tonics.  When  the  seques- 
trum becomes  loose,  enlarge  the  cloaca  with  the  chisel, 
gouge,  and  rongeur,  remove  the  dead  bone  with  the  forceps, 
and  pack  the  cavity  with  iodoform  gauze.  This  operation  is 
known  as  "  sequestrotomy."  If  much  of  a  gap  is  left  by  the 
operation,  try  and  fill  this  gap  by  taking  flaps  of  skin  and 
fastening  them  to  the  bottom,  by  breaking  the  edges  of  the 
involucrum  and  turning  them  in,  or  by  inserting  bone-chips. 
These  chips,  which  are  obtained  from  the  compact  part  of 
the  tibia  or  femur  of  an  ox,  are  decalcified  by  being  placed 
for  a  couple  of  weeks  in  a  10  per  cent,  aqueous  solution  of 
hydrochloric  acid  (which  is  renewed  every  day) ;  they  are 
well  washed  in  a  weak  alkali  and  then  in  water,  are  cut  into 
strips,  are  soaked  for  two  days  in  a  i  :  looo  sublimate  solu- 
tion, and  are  kept  in  a  saturated  ethereal  solution  of  iodo- 
form. The  cavity  is  made  sterile  and  is  well  dusted  with 
iodoform,  the  bone-chips  are  dried  and  inserted  into  the 
involucrum,  a  capillary  drain  is  employed,  the  periosteum  is 
stitched  over  the  opening,  and  so  are  the  soft  parts ;  but  if 
this  cannot  be  done,  iodoform  packing  is  used  to  keep  the 
chips  in  place.     This  method  is  due  to  the  genius  of  Senn. 

Acute  diffuse  osteo-myelitis,  a  diffuse  inflammation  of 
bone  and  marrow,  is  due  to  infection  with  pyogenic  cocci 
(staphylococcus  pyogenes  aureus  and  streptococcus  pyoge- 
nes;  Figs.  11,12).  It  may  arise  from  a  wound,  such  as  a  com- 
pound fracture,  a  gunshot  injury,  or  an  amputation.     It  may 


304  ^   MANUAL    OF  SURGERY. 

occur  when  tlie  infection  has  been  by  way  of  the  blood.  In 
osteo-mycHtis  from  wound  of  the  endosteum  the  medulla  and 
cancellous  tissue  inflame  and  suppurate.  The  entire  length 
and  thickness  of  the  shaft  may  be  involved,  and  the  peri- 
osteum becomes  infiltrated,  detached,  and  retracted  from  the 
edees  of  the  bone-wound.  The  soft  tissues  around  the  bone 
also  inflame  and  sometimes  slough.  More  or  less  necrosis 
is  inevitable. 

TJie  symptoms  of  aaite  osteo-myclitis  from  zvoiind  are — 
a  very  severe  boring,  gnawing,  aching  pain ;  great  tender- 
ness;  deep  swelling  of  the  soft  parts  over  the  bone;  the 
skin  is  healthy  early  in  the  case ;  a  profuse  offensive  puru- 
lent discharge  containing  bone-fragments  and  tissue-sloughs  ; 
the  periosteum  is  red,  thick,  and  separated ;  a  fungating  foul 
mass  protrudes  from  the  medullary  canal ;  rigors,  sweats, 
and  fever  point  to  septicaemia  or  pyaemia. 

Treatment. — In  treating  acute  osteo-myelitis,  the  following 
is  the  approved  method  :  Incision  ;  curetting  the  medullary 
cavity,  swabbing  it  out  with  pure  carbolic  acid,  and  packing 
it  with  iodoform  gauze ;  drainage  ;  antiseptic  dressings ;  fre- 
quent cleansing ;  and  strong  supporting  treatment.  When 
the  sequestrum  loosens,  it  should  be  removed.  Some  cases 
require  amputation. 

Acute  Epiphysitis. — Osteo-myelitis  without  a  wound  is 
called  "  acute  infantile  arthritis  "  or  "  acute  epiphysitis."  It 
affects  the  young,  especially  children  of  from  one  to  two 
years  of  age,  and  arises  at  the  epiphyseal  line.  A  strain 
occurs  at  this  point,  inflammation  follows,  and  a  hospitable 
welcome  is  extended  to  pus-organisms  passing  through  this 
area  by  means  of  the  body-fluids.  The  femur  and  tibia  are 
the  bones  most  often  attacked,  the  hip-joint  or  knee-joint 
being  secondarily  involved,  but  the  shoulder,  ankle,  or  elbow 
may  likewise  fall  a  victim.  The  youngest  bone  around  the 
ossific    centre    first    inflames,  necrosis    takes  place,  a  small 


DISEASES  AND   IXJURIES   OF  BONES  AND  JOINTS.      305 

sequestrum  forms,  and  the  pus  around  the  sequestrum 
makes  a  cloaca  and  empties  into  the  adjacent  joint,  hght- 
ing  up  a  suppurative  inflammation. 

The  syiuptonis  of  acute  epiphysitis  usually  come  on  sud- 
denly at  night ;  the  attack  is  generally  ushered  in  by  a  chill 
which  is  followed  by  septic  febrile  temperature.  It  will  likely 
be  found  as  a  cause  that  the  patient  was  suddenly  chilled 
after  being  overheated  (sitting  in  a  cellar  on  a  hot  day,  swim- 
ming when  very  warm,  etc.).  There  is  severe  aching  pain 
and  great  tenderness  near  the  joint ;  the  soft  parts,  which  at 
first  are  healthy  in  appearance,  after  a  time  discolor,  swell, 
and  present  distended  veins ;  the  neighboring  joint  swells 
and  becomes  filled  with  pus;  the  periosteum  and  the  shaft 
are  involved  for  a  considerable  distance ;  each  epiphysis  may 
become  affected,  the  shaft  between  being  comparatively  un- 
involved,  and  the  epiphyses  may  separate,  displacement  and 
shortening  taking  place.  This  disease  is  often  mistaken  for 
rheumatism  because  of  the  joint-swelling,  for  typhoid  fever 
because  of  the  fever,  and  in  some  cases  for  erysipelas  because 
of  the  redness  of  the  skin.  This  disease  offers  a  very  grave 
prognosis. 

Treatment. — In  treating  acute  epiphysitis,  incise  at  once  ; 
trephine  the  bone  at  one  or  more  points ;  curette ;  irrigate 
with  corrosive-sublimate  solution  ;  swab  out  with  pure  car- 
bolic acid ;  use  iodoform  plentifully ;  drain  the  joint  if  it 
contains  pus  ;  employ  rest,  anodynes,  and  strong  supporting 
treatment.  Remove  dead  bone  when  it  becomes  loose. 
Amputation  may  be  required. 

Chronic  osteo -myelitis  is  usually  linked  with  osteitis.  It 
may  eventuate  in  osteo-sclerosis  with  filling  up  of  the  medul- 
lary canal,  or  in  suppuration  of  the  cancellous  tissue  (Brodie's 
abscess).  A  tubercular  inflammation  is  one  form  of  chronic 
osteo-myelitrs. 

Osteo-malacia,  or  Mollities  Ossium. — In  this  disease  the 
20 


306  A   MANUAL    OF  SURGERY. 

bones  are  partly  decalcified,  and  consequently  soften  and 
bend.  Many  bones  are  usually  involved.  It  is  commoner 
beyond  than  before  middle  age,  though  it  may  occur  in 
infancy ;  it  is  commoner  in  women  than  in  men,  and 
pregnancy  seems  to  bear  more  than  a  casual  relation  to  its 
production.  In  osteo-malacia  the  medulla  increases  in  bulk 
and  becomes  more  fatty,  and  the  osseous  matter  is  absorbed 
gradually,  first  from  cancellous  tissue  and  then  from  the 
compact  tissue.  Some  observers  believe  this  curious  con- 
dition is  due  to  lactic  acid  in  the  blood. 

Symptoms. — The  symptoms  of  osteo-malacia  are  as  fol- 
lows :  many  points  of  pain  which  is  often  thought  to  be  due  to 
rheumatism  ;  deformities  from  twisting  and  bending  of  bone ; 
and  a  large  excess  of  calcium  salts  in  the  urine.  This  disease 
lasts  a  number  of  years,  but  usually  causes  death  from  ex- 
haustion, though  some  few  cases  are  arrested  or  cured. 
Fractures  occur  from  very  slight  force. 

Treatment. — In  treating  osteo-malacia  in  women,  insist 
that  pregnancy  must  not  occur.  Put  braces  and  supports 
upon  distorted  limbs  to  prevent  fracture.  Advise  good  air, 
hygienic  surroundings,  and  nourishing  food.  Among  the 
medicines  that  can  be  used  may  be  mentioned  cod-liver  oil, 
lime  salts,  and  preparations  of  phosphorus. 

2.  Fractures. 

Definition. — A  fracture  is  a  solution,  by  sudden  force,  of 
the  continuity  of  a  bone  or  of  a  cartilage.  Clinically,  under 
this  head  are  placed  epiphyseal  separations  and  the  tearing 
apart  of  ribs  and  their  cartilages. 

Varieties  of  Fractures. — The  varieties  of  fractures  are 
as  follows : 

Simple  fracture  is  a  subcutaneous  fracture,  or  one  in  which 
no  open  wound  admits  air  to  the  seat  of  bone-injury.  This 
corresponds  to  a  contusion  of  the  soft  parts. 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      307 

Conipotuid  fracture  is  an  open  fracture,  or  one  in  which  an 
open  wound  admits  air  to  the  seat  of  bone-injury.  This  corre- 
sponds to  a  contused  or  lacerated  wound  of  the  soft  parts. 

A'piimary  compotmd  fracture  is  one  in  which  the  breach 
in  the  soft  parts  is  occasioned  at  the  time  of  the  accident, 
either  by  the  direct  violence  of  the  injury  or  by  the  forcing 
of  a  bone  or  bones  through  the  tissues. 

A  secondary  compoimd  fracture  is  one  in  which  the  breach 
in  the  soft  parts  occurs  after  the  accident,  either  from  slough- 
ing of  damaged  tissues,  from  ulceration  from  the  pressure 
of  ill-adjusted  fragments,  or  from  the  forcing  of  a  bone  or 
bones  through  the  soft  parts  because  of  rough  handling, 
neglect,  or  the  tossing  of  delirium. 

Complicated  fracture  is  a  fracture  plus  the  complication 
of  a  joint-injury,  arterial  or  venous  damage,  or  injury  to 
the  nerves  or  soft  parts.  When  a  fractured  rib  injures  the 
lung  or  when  a  broken  vertebra  damages  the  spine  we  have 
a  complicated  fracture.  The  term  is  a  bad  one,  as  it  con- 
veys no  definite  meaning,  and  is  no  more  justifiable  than  it 
would  be  to  speak  of  "complicated  pneumonia"  or  "com- 
plicated typhoid,"  for  we  should  always  give  a  name  to  the 
complication  in  any  case.  It  should  be  remembered  that 
damage  to  the  soft  parts  not  sufficient  to  admit  air  to  the 
seat  of  fracture  does  not  make  the  case  a  compound  fracture, 
but  rather  complicates  a  simple  fracture.  Remember  also 
that  these  areas  of  tissue-destruction  must  be  treated  anti- 
septically,  otherwise  absorption  of  pus-elements  and  their 
deposition  at  the  seat  of  injury  may  cause  diffuse  osteo- 
myelitis. 

Complete  fracture  is  that  which  extends  through  the  whole 
thickness  of  a  bone  or  entirely  across  it. 

Incomplete  fracture  is  that  which  extends   only  partially 

through  the  thickness  of  a  bone  or  only  partially  across  it. 

A  linear,  hair,  capillary,  or  fissured  fracture,  or  a  fissure. 


308  A   MANUAL    OF  SURGERY. 

is  a  crack  in  a  bone  with  very  little  separation.  This  is  an 
incomplete  fracture,  but  may  be  associated  with  a  complete 
break. 

A  green-sticky  hickory -stick,  willozv,  or  boit  fracture  is  a 
true  incomplete  break.  It  is  commonest  in  the  forearm  or 
clavicle,  it  arises  from  indirect  force,  and  it  is  very  rare  after 
the  age  of  sixteen.  It  is  called  "  green-stick  "  because  the 
bone  breaks  like  a  green  stick  when  forced  across  the  knee, 
first  bending  and  then  breaking  on  its  convex  surface.  The 
bone,  being  compressed  between  two  forces,  bends,  and  the 
fibres  on  the  outer  side  of  the  curve  are  pulled  apart,  while 
those  on  its  concavity  are  not  broken,  but  are  compressed. 
In  correcting  the  deformity  the  fracture  is  apt  to  be  made 
complete.  The  permanent  bending  of  a  bone  without  a 
break  may  possibly  occur  in  youth. 

Depression-fracture  occurs  when  a  portion  of  the  thickness 
of  a  bone  is  driven  in  by  crushing.  Fracture  by  depression 
is  a  result  of  the  bending  in  of  a  bone  (as  the  parietal),  a 
fragment  breaking  off  from  the  side  toward  which  the  bone 
is  bending.  A  depressed  fracture  is  complete,  not  incom- 
plete, and  by  this  term  is  meant  an  injury  in  which  a  frag- 
ment of  the  entire  thickness  of  the  bone  is  driven  below  the 
level  of  the  surrounding  surface. 

Splinter-  and  Strain-fracture. — The  breaking  off  of  a 
splinter  of  bone  (splinter-fracture)  or  of  an  apophysis  con- 
stitutes an  incomplete  fracture.  A  strain  upon  a  ligament 
may  tear  off  a  shell  of  bone,  and  this  injury  is  the  "  strain- 
fracture  "  of  Callender. 

Longitudinal  fractiire  is  a  fracture  whose  line  is  for  a  con- 
siderable distance  parallel,  or  nearly  so,  with  the  long  axis 
of  the  bone.     This  is  common  in  gunshot  injuries. 

Oblique  fracture  is  a  fracture  whose  line  is  positively 
oblique  to  the  long  axis  of  the  bone.  Most  fractures  from 
indirect  force  are  oblique. 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      3O9 

Transverse  fracture  is  a  fracture  whose  line  is  nearly- 
transverse  to  the  long  axis  of  the  bone  (no  fracture  is 
mathematically  transverse).  The  general  cause  here  is  direct 
force.  The  ''fracture  en  rave''  (radish  fracture,  so  called 
because  the  bone  breaks  as  does  a  radish)  is  transverse  at 
the  surface,  but  not  within. 

Toothed  or  dentate  fracture  is  a  form  of  fracture  in  which 
the  end  of  each  fragment  is  irregularly  serrated  and  the  frag- 
ments are  commonly  locked  together ;  hence  the  deformity 
is  hard  to  correct.  Most  of  the  simple  fractures  from  direct 
force  are  serrated. 

Wedge-shaped,  V-shaped,  cnneated,  or  cuneiform  fracture 
("  fracture  oblique  spiroide,"  "  fracture  en  V  "  of  Gosselin, 
"  fracture  en  coin  ")  is  a  fracture  whose  line  has  the  shape 
of  a  V,  which  may  be  entire  or  may  want  the  point.  It 
occurs  at  the  articular  extremity  of  a  long  bone,  and  a  fissure 
usually  arises  from  its  point  and  enters  the  joint.  If  com- 
plete, it  is  a  "  comminuted  fracture." 

T-shaped  fracture  is  a  fracture  which  presents  a  transverse 
or  oblique  line  and  also  a  longitudinal  or  vertical  line.  It 
occurs  at  the  lower  end  of  either  the  humerus  or  femur,  the 
transverse  line  being  above,  and  the  vertical  line  (inter- 
condyloid)  between,  the  condyles.  If  complete,  it  is  in 
reality  a  form  of  comminuted  fracture. 

Designations  According  to  Seat  of  Fracture. — Fractures 
are  designated  also  according  to  their  anatomical  seats ;  for 
instance,  fracture  of  the  upper  third  of  the  shaft  of  the  femur, 
fracture  of  the  olecranon  process  of  the  ulna,  fracture  of  the 
middle  third  of  the  clavicle,  and  fracture  of  the  body  of  the 
lower  jaw.  Intra-articular  fracture  is  one  extending  into 
a  joint ;  intracapsular  fracture  is  one  within  the  capsule  of 
either  the  shoulder-  or  hip-joint ;  and  extracapsular  fracture 
is  one  just  without  the  capsule  of  either  the  shoulder-  or 
hip-joint. 


310  A   MANUAL    OF  SURGERY. 

Mjiltiplc  or  composite  fracture  is  a  condition  in  which  a 
bone  is  broken  into  more  than  two  pieces,  the  Hnes  of  frac- 
ture not  intercommunicating,  or  a  condition  in  which  two 
or  more  bones  are  broken.  Multiple  fractures  of  one  bone 
are  divided  into  double,  treble,  quadruple,  etc. 

Comminuted  fracture  is  a  condition  in  which  a  bone  is 
broken  into  more  than  two  pieces,  the  lines  of  fracture  inter- 
communicating. The  bone  may  be  broken  into  many  small 
fragments,  may  present  much  splintering,  or  may  actually  be 
ground  up. 

Impacted  fraciiire  is  one  in  which  one  fragment  is  driven 
into  the  other  and  solidly  wedged. 

Fracture  ivith  crtisJiing  is  an  impacted  fracture  in  which 
the  encasing  bone  is  so  crushed  and  splintered  that  the 
impacting  bone  is  not  firmly  held. 

Pathological,  spontaneous,  or  secondary  fracture  is  one 
occurring  from  a  very  insignificant  force  acting  on  a  bone 
rendered  brittle  by  disease. 

Ununited  fracture  is  a  term  used  to  designate  a  fracture 
in  which  bony  union  is  absent  after  the  passage  of  the  period 
normally  necessary  for  its  occurrence. 

Direct  fracture  is  one  occurring  at  the  primary  point  of 
the  application  of  force. 

Indirect  fracture  is  one  occurring  at  a  point  distant  from 
the  area  of  the  primary  application  of  force. 

Stellate  or  starred  fracture  (fracture  par  irradiation)  is  one 
in  which  several  fissures  radiate  from  a  centre.  If  the  frac- 
ture be  complete,  it  is  in  reality  a  form  of  comminuted 
fracture. 

Helicoidal,  spiral,  or  torsion  fracture  is  a  fracture  resulting 
in  a  long  bone  from  twisting. 

Fracture  by  contre-coup  is  a  fracture  of  the  skull  which  is 
not  at,  but  opposite  to,  the  point  of  application  of  force. 

Epiphyseal  Separation  or  Diastasis. — This   injury  occurs 


DISEASES  AND  INJURIES   OF  BONES  AND  JOINTS.      31I 

only  before  the  age  of  twenty-five  and  is  commonest  at  the 
lower  end  of  the  femur,  but  it  is  encountered  also  at  the 
lower  ends  of  the  tibia  and  radius  and  at  both  extremities 
of  the  humerus.  This  injury  induces  deformity  which  is 
often  hard  to  reduce,  and  by  damaging  the  cartilage  may 
retard  or  inhibit  a  further  lengthening  by  growth  of  the  limb. 

Iiitra-titerine  fractures  are  usually  due  to  injuries  of  the 
mother's  abdomen  sustained  toward  the  end  of  pregnancy. 
Some  hold  that  they  can  arise  as  a  consequence  of  the 
force  of  violent  uterine  contractions.  Many  so-called  "  intra- 
uterine "  fractures  are  wrongly  named,  as  they  result  from 
injury  during  delivery.  In  sporadic  cretinism  (misnamed 
congenital  rickets)  the  bones  are  fragile  and  ill-ossified,  and 
many  fractures  may  occur  in  iitero. 

Causes  of  Fracture. — The  causes  of  fracture  are  (i)  ex- 
citing, immediate  or  direct,  and  (2)  predisposing  or  indirect. 

Exciting  causes  are  (a)  external  violence  and  {b)  muscular 
action. 

External  violence  is  the  most  usual  exciting  cause.  Two 
forms  are  noted  :  (i)  direct  violence  and  (2)  indirect  force. 

Fractures  front  direct  violence  occur  at  the  point  struck, 
as  when  the  nasal  bones  are  broken  with  the  fist.  In  such 
fractures  the  soft  parts  are  damaged  ;  they  may  be  destroyed 
at  once  in  part,  they  may  be  damaged  so  severely  that  a 
portion  sloughs,  or  they  may  be  damaged  so  slightly  that  they 
do  not  lose  vitality ;  hence  fractures  by  direct  violence  may 
be  compound  from  the  start,  may  become  so,  or  may  remain 
simple.  In  compound  fractures  by  direct  violence  the  soft- 
part  injury  is  so  great  that  primary  tissue-union  cannot  occur. 

Fractures  from  indirect  force  do  not  occur  at  the  point 
of  application  of  the  force,  but  at  a  distance  from  it,  the 
force  being  transmitted  through  a  bone  or  a  chain  of  bones. 
Such  fractures  tend  to  occur  in  regions  of  special  predilection. 
If  they  are  not  compound,  there  is  no  injury  of  the  tissues 


312  A   MANUAL    OF  SURGERY. 

over  the  fracture.  If  they  become  compound  by  projection 
of  fragments,  primary  union  may  still  occur. 

Muscular  action  is  a  rather  rare  cause.  Fractures  thus 
produced  result  from  sudden  or  violent  contraction.  Bones 
so  broken  are  usually  diseased.  Violent  coughing  may 
fracture  the  ribs  ;  attempting  to  kick  may  fracture  the  femur ; 
saving  one's  self  from  falling  backward  may  fracture  the 
patellae ;  throwing  a  stone  may  fracture  the  humerus  ;  and 
sudden  extension  of  the  forearm  may  fracture  the  olecranon 
process  of  the  ulna. 

Predisposing  Causes. — There  are  two  classes  of  predispos- 
ing causes,  namely  :  (i)  physiological,  natural  or  normal,  and 
(2)  pathological  or  abnormal. 

Natural  Predisposing  Causes. — Under  this  head  is  consid- 
ered the  liability  to  fracture  possessed  by  individual  bones 
because  of  their  shape,  structure,  function,  or  position. 
Those  predispositions  occasioned  by  special  ages  are  also 
considered.  In  youth  epiphyseal  separation  is  commoner 
than  fracture,  and  a  fracture  is  apt  to  be  incomplete.  Frac- 
tures are  commonest  between  the  ages  of  twenty-five  and 
sixty.  From  two  to  four  years  of  age  a  child  is  more  liable 
to  fracture  than  later,  because  he  is  then  learning  to  walk 
(Malgaigne).  The  bones  of  the  old  are  easily  broken,  but 
the  normal  lack  of  activity  of  the  aged  saves  them  from 
more  frequent  injury.  Thus  the  predispositions  of  age  are 
in  part  due  to  habits  and  in  part  to  bony  structure.  The 
bones  of  the  young,  being  elastic,  bend  considerably  before 
they  break ;  the  bones  of  the  old,  being  brittle  and  inelastic, 
break  easily,  but  do  not  bend.  In  old  age  the  bones  become 
lighter  and  more  porous,  though  they  do  not  diminish  in 
size.  An  absorption  takes  place  from  the  interior  of  a  bone, 
particularly  at  its  articular  head,  the  medullary  canal  in- 
creases in  size,  the  cancellous  spaces  become  notably  larger, 
and  portions  of  the  remaining  bone  of  the  interior  show 


DISEASES  AND  INJURIES   OF  BONES  AND  JOINTS.      313 

a  fatty  change.  There  is  no  increase  in  the  amount  of  min- 
eral salts  present,  as  was  long  taught.  These  alterations 
occur  earlier  in  women  than  in  men/  The  change  of  age 
is  a  diminution  in  the  amount  of  bone  present,  and  sometimes 
a  fatty  change  in  a  portion  of  what  remains.  If  the  atrophy 
of  bone  is  other  than  that  normal  to  senility,  it  constitutes 
a  pathological  predisposing  cause  of  fracture.  Normal  pre- 
disposing causes  include  the  person's  weight  (which  deter- 
mines the  force  of  a  fall),  muscular  development,  habits,  sex, 
occupation,  and  the  season  of  the  year. 

Pathological  Predisposing  Causes. — Hereditary  fragility  is 
a  condition  commonest  among  women,  often  existing  in 
generation  after  generation,  and  in  which  condition  fractures 
occur  from  an  infinitely  slight  force.  There  exists  in  these 
cases  bony  rarefaction — in  fact,  a  premature  senility. 

Nervous  Diseases. — Bony  nutrition  is  dependent  on  the 
spinal  cord,  and  the  trophic  influence  is  probably  exerted 
through  the  posterior  nerv^e-roots  (Gowers).  In  diseases  of 
the  anterior  cornua  bony  growth  is  much  interfered  with  ; 
in  diseases  of  the  posterior  columns,  as  in  locomotor  ataxia, 
a  true  bony  atrophy  bespeaks  trophic  disorder.  Syringo- 
myelia causes  brittleness  of  the  bones,  and  in  paralysis  agitans 
they  are  thought  to  break  easily.  Trophic  changes  may 
occur  in  the  bones  of  the  insane,  most  commonly  when 
insanity  is  linked  to  organic  disease.  About  one-quarter 
of  paretic  dements  show  undue  brittleness  or  unnatural  soft- 
ness of  bone.^  The  bones  of  maniacs  are  frequently  fragile. 
In  asylum  practice  fractures  are  not  necessarily  an  indication 
of  abuse. 

Rickets. — Rickets  predisposes  to  fracture  because  of  altered 
bone-structure  and  the  great  liability  to  falls. 

Atrophy'  of  Bone. — This  condition,  as  has  been  seen 
(p.  295),  is  normal  in  senility.     It  may  arise  from  want  of 

*  Humphrey  on   Old  Age.  ^  Spitzka's  Manual  of  Insanity. 


314  A   MANUAL    OF  SURGERY. 

use,  as  is  observed  in  the  bedfast,  in  the  wasted  femur  of 
hip-joint  disease,  and  in  the  bones  of  a  stump.  It  may 
arise  from  pressure,  as  when  an  aneurysm  compresses  the 
ribs,  sternum,  or  vertebrae.  Among  other  of  the  patho- 
logical predisposing  causes  are  to  be  mentioned  cancer, 
sarcoma,  and  hydatid  cysts  of  bone,  caries,  necrosis,  gout, 
scrofula,  syphilis,  moUities  ossium,  and  scurvy. 

Symptoms  of  Fracture. — History  of  an  Injury. — In  spon- 
taneous fracture  there  may  be  no  record  of  violence ;  for  in- 
stance, when  a  bone  breaks  while  turning  in  bed.  In  inves- 
tigating the  history,  not  only  seek  for  violence,  but  determine 
exactly  how  the  accident  happened. 

A  sound  of  cracking  is  occasionally  audible  to  a  bystander 
at  the  time  of  the  injury.  The  patient  may  have  heard  it, 
but  very  rarely  does.  A  rupture  of  a  tendon  or  a  ligament 
produces  a  similar  sound. 

Pain  is  usually,  but  not  invariably,  present  (absent  often  in 
rickets).  Malgaigne  says  that  in  some  fractures  the  pain  is 
slight  or  absent,  in  others  it  is  torturing,  and  in  most  it  is 
severe  for  a  time  after  the  injury,  but  gradually  abates  unless 
reinduced  by  movement.  Pain  developed  at  the  time  of  the 
accident  is  far  less  important  as  a  symptom  than  that  which 
can  subsequently  be  produced  by  movement.  In  indirect 
fractures  there  is  an  area  of  pain  at  the  point  of  application 
of  the  force,  and  another  at  the  seat  of  fracture.  Pain  at  the 
seat  of  fracture  can  infinitely  be  aggravated  by  pressure  or 
movement  and  is  rather  narrowly  localized. 

Deformity  or  alteration  in  length  or  outline  is  due  in  part  to 
swelling  and  in  part  to  a  change  in  the  mutual  relation  of 
the  fragments  (displacement).  The  deformity  of  swelling  is 
no  aid  to  a  diagnosis,  as  the  same  thing  occurs  in  contusion, 
and  it  often  hides  some  positive  symptomatic  distortion.  The 
swelling  is  due  first  to  blood  and  next  to  inflammatory  prod- 
ucts and    pressure-oedema,  and  is  very  great  in   joint-frac- 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      315 

tures.  The  deformity  of  displacement  may  be  produced  by 
the  violence  of  the  injury  (as  is  the  depression  in  a  skull- 
fracture),  by  the  weight  of  an  extremity  (as  is  the  falling  of 
the  shoulder  in  a  fracture  of  the  clavicle),  or  by  muscular 
action  (as  is  the  pulling  upward  of  the  superior  fragment  of 
a  fractured  olecranon  process). 

The  varieties  of  displacement  are  (i)  transverse  or 
lateral,  where  one  fragment  goes  to  the  side,  front,  or  back, 
but  does  not  overlap  the  other;  (2)  angular,  the  bony  axis 
at  the  point  of  fracture  being  altered  and  the  fragments 
forming  with  each  other  an  angle ;  (3)  rotary,  one  fragment 
rotating  in  the  bony  circumference,  the  other  remaining 
stationary.  As  a  rule,  it  is  the  lower  fragment  which  turns 
on  its  long  axis,  rotating  with  it  the  limb  below  the  level  of 
the  break;  (4)  overlapping  or  overriding,  when  the  upper 
level  of  one  fragment  is  above  the  lower  level  of  the  other 
fragment.  It  is  usually  the  lower  fragment  which  is  drawn 
by  the  muscles  above  the  upper,  but  the  body-weight  and 
sliding  down  in  bed  may  push  the  upper  below  the  lower. 
In  overriding  the  ends  are  near  together  and  the  bones  are 
usually  in  contact  at  their  periphery.  It  is  obvious  that 
overlapping  is  associated  with  transverse  displacement,  as  one 
fragment  must  go  front,  back,  or  to  the  side;  (5)  penetration 
or  impaction  is  when  one  fragment  is  driven  into  the  other, 
thus  producing  shortening;  (6)  separation  oi  the  two  frag- 
ments occurs  in  fracture  of  the  patella,  olecranon,  os  calcis, 
certain  articulations,  and  in  some  breaks  of  the  humerus 
when  the  arm  is  not  supported. 

It  is  important  to  remember  that  a  dislocation  may  produce 
displacement,  but  these  two  conditions  may  be  differentiated 
by  the  observation  that  the  displacement  of  fracture  tends 
to  reappear  after  complete  reduction,  while  that  of  dislocation 
does  not  reappear.  A  displacement  is  hard  to  detect  in  a  flat 
bone  and  when  one  of  two  parallel  bones  is  broken. 


3l6  A   MANUAL    OF  SURGERY. 

Loss  of  fimction  may  be  shown  by  inability  to  move  the 
limb  because  of  the  break,  but  it  is  not  always  markedly 
present,  though  some  degree  invariably  exists.  It  is  slight 
in  "  green-stick  "  and  impacted  fractures  (unless  arising  from 
pain  or  nerve-injury).  A  person  can  walk  when  the  fibula 
alone  is  broken,  and  likewise  in  some  cases  of  intracapsular 
fracture  of  the  femur,  and  can  often  put  the  hand  on  the 
head  in  fractured  clavicle  (Malgaigne).  The  pain  of  any 
injury  or  the  loss  of  power  from  nerve- traumatism  may 
cause  loss  of  movement  in  the  limb.  This  symptom  is 
of  slight  diagnostic  value  in  most  fractures. 

Extravasation  of  Blood. — A  contusion  of  the  surface  ac- 
companied by  skin-abrasion  indicates  merely  the  point  of 
application  of  direct  external  violence.  If  contusion  is  exten- 
sive over  a  superficial  bone,  as  the  tibia  or  parietal,  after 
a  few  hours  it  often  simulates  fracture  by  presenting  a  soft, 
compressible  centre  surrounded  by  a  ring  of  hard,  condensed 
tissues  and  coao-ulated  blood.  Direct  external  violence 
may  merely  occasion  ecchymosis,  and  in  fracture  from 
indirect  force  ecchymosis  may  occur  in  a  considerable  area. 
In  regard  to  this  symptom,  note  that  even  great  external 
violence  may  occasion  no  evident  contusion  or  ecchymosis, 
and  in  any  fracture  this  symptom  may  be  present  or  absent. 
In  old  people  extravasation  of  blood  is  frequently  marked 
and  persistent.  By  suggillation  is  meant  an  extravasation 
of  blood  which  slowly  invades  wide  areas  of  tissue  and 
which  appears  at  the  surface  only  after  some  time,  and  then 
usually  as  a  yellowish  discoloration.  Linear  ecchymosis 
has  been  esteemed  by  some  as  a  sign  of  fissure,  and  it  often 
follows  fracture  of  the  fibula. 

Pretei'Jiatitral  mobility  is  a  most  important  symptom,  which 
is  pathognomonic  when  found.  The  unbroken  bone  is  nowhere 
mobile  in  continuity,  and  by  preternatural  mobility  is  meant 
that  a  bone  is  mobile  in  continuity  or  that  there  is  abnormal- 


DISEASES  AND   INJURIES   OF  BOXES  AXD  JOIXTS.      317 

ity  in  the  direction  or  extent  of  joint-mobility.  In  some  frac- 
tures this  symptom  does  not  exist  (impacted,  green-stick,  and 
locked  serrated  fractures) ;  in  others  it  cannot  be  found  (frac- 
tures of  tarsus,  carpus,  vertebral  bodies);  in  others  it  is  difficult 
to  obtain,  but  at  times  can  be  developed  (fractures  near  or 
into  many  joints).  To  develop  this  symptom,  try,  when  the 
case  admits,  to  grasp  the  fragments  and  to  move  them 
in  opposite  directions.  In  fractures  of  the  shafts  of  the 
femur  or  humerus,  fix  the  upper  fragments  and  carry  the 
knee  or  elbow  in  various  directions  to  develop  bending 
at  the  point  of  fracture.  In  fractured  clavicle,  push  the 
shoulder  downward  and  inward.  In  fractures  of  either  bone 
of  the  forearm,  grasp  the  opposite  bone  with  four  fingers 
of  each  hand  and  make  pressure  on  the  suspected  bone 
alternately  with  either  thumb ;  the  same  proceeding  being 
used  in  fractures  of  the  leg.  In  fractures  of  the  neck  of  the 
femur,  note  the  rotation  arc  of  the  great  trochanter  (Desault). 
In  fractures  of  the  lower  end  of  the  radius,  bend  the  hand 
back,  and  in  those  of  the  lower  end  of  the  fibula,  evert  the 
foot  (Alaisonneuve).  In  seeking  preternatural  mobility,  re- 
member that  the  elastic  ribs  when  being  forced  in  give  a 
sense  of  bending,  and  that  the  fibula  at  its  middle  is  "nor- 
mally flexible  "  (Dupuytren).  Some  rhachitic  bones  may  be 
bent. 

Crepitus  or  crepitation  is  both  a  sensation  and  a  sound, 
which  indicates  the  grating  together  of  the  two  rough  sur- 
faces of  a  broken  bone.  This  symptom  is  of  great  value, 
but  it  is  not  always  present.  It  is  absent  in  locked  serrated 
fractures,  in  impacted  fractures,  in  cases  where  the  broken 
ends  cannot  be  approximated  (as  in  overlapping),  and  is  rare 
when  a  fractured  surface  is  against  the  side,  and  not  the 
broken  face,  of  the  other  fragment,  and  is  unusual  in  incom- 
plete fractures.  Crepitus  is  often  absent  in  epiphyseal  sepa- 
ration, in  softened  bones,  and  in  fractures  in  or  near  joints,  and 


3l8  A   MANUAL    OF  SURGERY. 

it  may  be  prevented  from  occurring  by  blood-clot,  fascia,  or 
muscle  between  the  broken  surfaces.  The  grating  found  in 
teno-synovitis  must  not  be  mistaken  for  the  crepitus  of  frac- 
ture :  the  former  is  diffused,  large,  soft,  and  moist ;  the  latter 
is  limited,  small,  harsh,  and  dry.  The  clicking  of  an  inflamed 
or  eroded  joint  and  the  crackling  of  emphysema  must  also 
be  separated  from  bony  crepitus.  Crepitus  of  fracture  may 
be  present  at  one  moment,  but  absent  the  next.  It  is  often 
not  detected  during  the  time  swelling  is  marked,  and  cannot 
be  discovered  after  organization  of  the  callus  begins.  In  but 
few  fractures  is  it  needful  to  try  and  hear  crepitus  with  the 
naked  ear  or  with  a  stethoscope  upon  the  part,  but  in  doubt- 
ful cases  of  fractures  of  ribs  and  joints  it  should  be  tried. 

The  above-named  symptoms  are  known  as  "  direct."  There 
are  other  symptoms  known  as  **  circumstantial,"  such  as  the 
flow  of  blood  and  cerebro-spinal  fluid  from  the  ear  after 
some  fractures  of  the  middle  fossa  of  the  skull ;  emphysema 
of  the  face  and  epistaxis  after  fractures  of  the  nasal  bones ; 
haemoptysis  and  emphysema  after  crushes  of  the  chest;  dis- 
coloration following  the  line  of  the  posterior  auricular  artery 
after  fractures  of  the  posterior  fossa  of  the  skull ;  and  sub- 
conjunctival ecchymosis  after  fractures  of  the  anterior  fossa 
of  the  skull. 

Diagnosis. — Examine  as  soon  as  practicable  after  the 
injury — before  the  onset  of  swelling,  if  possible.  Expose 
the  part  completely,  taking  off  the  clothing,  if  necessary, 
by  clipping  it  along  the  seams.  Compare  the  part,  by 
attentive  scrutiny,  with  the  same  part  on  the  opposite  side. 
If  any  deformity  be  present,  it  must  be  ascertained  that  it 
did  not  exist  before  the  accident.  If  the  nature  of  the  injury 
be  uncertain,  if  the  patient  be  very  nervous,  or  if  the  part  be 
acutely  painful,  it  is  better  to  give  ether  to  diagnosticate,  and 
set  and  dress.  In  injuries  of  the  elbow-joint  always  anaes- 
thetize before  examination  (Brinton). 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      319 

A  fracture  is  distinguished  from  a  dislocation  by  its 
preternatural  mobility,  its  easily-reduced  but  recurring  dis- 
placement, and  its  crepitus,  as  against  the  preternatural 
rigidity,  the  deformity,  difficult  to  reduce,  but  remaining  re- 
duced, and  the  absence  of  crepitus  of  a  dislocation.  Further, 
in  dislocation  the  bone,  when  rotated,  moves  as  one  piece, 
whereas  in  fracture  it  does  not  so  move ;  in  dislocation  the 
bony  processes  are  felt  occupying  their  proper  relations  to 
the  rest  of  the  same  bone,  while  in  fracture  some  of  them 
present  altered  relations ;  in  dislocation  the  head  of  the 
bone  is  found  out  of  its  socket,  but  in  fracture  it  is  felt  in  its 
place.  It  is  important  to  remember,  moreover,  that  a  frac- 
ture and  a  dislocation  may  occur  together,  and  that  the 
rubbing  of  a  dislocated  bone  against  an  articular  edge  when 
the  joint  has  been  roughened  by  inflammation  simulates 
crepitus. 

Great  contusion,  by  inducing  extreme  tumefaction,  may 
mask  characteristic  deformity  and  obscure  crepitus.  When 
only  a  contusion  exists,  pain  is  apt  to  be  diffused,  but  if  a 
fracture  has  occurred,  the  pain  is  accentuated  at  some  narrow 
spot.  In  many  cases,  before  he  can  give  a  certain  opinion, 
the  surgeon  must  wait  some  days  until  the  swelling  has 
largely  subsided.  In  such  a  case  it  is  best  to  assume  in  our 
treatment  that  a  fracture  exists  until  the  contrary  is  known. 
Combat  swelling  by  rest,  lead-water  and  laudanum,  and  mod- 
erate com.pression. 

In  impaction  the  diagnosis  is  difficult.  The  moderate 
deformity  is  concealed  by  swelling,  crepitus  and  preternatural 
mobility  do  not  exist  unless  the  fragments  are  pulled  apart, 
and  there  is  not  necessarily  much  loss  of  function.  A  con- 
clusion is  reached  largely  by  considering  the  nature,  direc- 
tion, and  extent  of  the  violence,  the  seat  of  the  pain,  and  by 
a  careful  study  of  the  most  minute  deformity.  Fissures  are 
hard  to  recognize.    They  rarely  present  any  evidence  of  their 


320  A   MANUAL    OF  SURGERY. 

existence  except  a  localized  pain  and  a  linear  ecchymosis 
appearing  after  a  few  days. 

In  green-stick  fractures  the  age,  the  deformity,  and 
possibly  crepitus  during  reduction,  help  in  the  diagnosis. 
Epiphyseal  separations  are  diagnosticated  by  the  age,  the 
preternatural  mobility,  the  deformity,  the  situation  of  the 
injury,  and  the  absence  of  crepitus  or  the  presence  only  of 
a  soft  crepitus.  Fractures  are  often  hard  to  recognize  when 
occurring  in  a  group  of  bones  like  those  of  the  carpus  and 
tarsus  (which  are  firmly  joined  by  dense  ligaments)  or  in 
one  of  tw^o  parallel  bones.  There  is  not  always  a  certainty 
that  a  fracture  exists,  and  when,  after  a  careful  examination, 
there  is  still  an  uncertainty,  do  not  prolong  the  efforts  or  use 
great  force,  but  treat  the  case  as  a  fracture  until  a  cure 
ensues  or  the  diagnosis  becomes  apparent. 

Complications  and  Consequences. — Some  of  the  conse- 
quences and  complications  of  fractures  are — sloughing  of  the 
soft  parts,  thus  making  the  fracture  compound ;  extravasa- 
tion of  blood,  causing  swelling  or  even  gangrene  ;  rupture 
of  the  main  artery  or  vein  of  the  limb ;  dislocation ;  oedema 
from  pressure  of  extravasated  blood,  from  inflammatory  ex- 
udation, from  tight  bandaging,  from  thrombosis,  or,  later, 
from  the  pressure  of  callus  ;  stiffness  of  joints  from  synovitis 
with  adhesion,  from  displaced  fragments,  or  from  intra-artic- 
ular  callus ;    stiffness   of  tendons   from  adhesive  thecitis  or 
from  the  presence  of  callus ;  paralysis  from  traumatic  neuri- 
tis or  the  pressure   of  callus  upon  nerve-trunks ;  muscular 
spasm ;    painful    callus ;    exuberant    callus ;    embolism ;    fat- 
embolism  ;   pulmonary   congestion  ;   gangrene ;  shock ;  sep- 
ticaemia; pysemia ;  tetanus;  delirium  tremens;  urinary  reten- 
tion ;  extensive  laceration  of  the  soft  parts  ;  rupture  of  a  large 
nerve  ;  and  involvement  of  a  joint. 

Repair  of  Fractures. — Simple  Fracture. — In  a  simple  frac- 
ture the  bone  is  broken,  the  soft  parts  are  lacerated,  and  the 


DISEASES  AND   INJURIES   OF  BOiVES  AND  JOINTS.      32 1 

periosteum  is  stripped  up  from  the  fragments  and  nearly,  but 
not  quite,  torn  through  ("periosteal  bridge"  remains).  As 
a  result  of  these  breaks  and  tears  blood  is  effused,  which  is 
presently  absorbed  and  is  not  an  element  in  the  healing 
process.  The  ends  of  the  bone-fragments  inflame  along 
with  the  periosteum  and  soft  parts,  exudation  occurs,  the 
adjacent  area  softens,  new  vessels  form,  and  there  results  a 
mass  of  embryonic  tissue  known  as  "callus."  Callus  is  of 
two  kinds  :  the  intcruicdiatc,  definitive,  or  permanent — that 
which  is  directly  between  the  fractured  ends ;  and  the 
provisional  or  temporary — that  within  the  medullary  canal 
(cetitral  callus)  and  external  to  the  bone  {ensheatJnng  callus). 
This  latter  callus  is  presently  converted  into  fibrous  tissue 
and  then  into  bone,  the  only  portion  passing  through  a 
cartilage  stage  being  that  which  emanates  from  the  "  peri- 
osteal bridge."  The  amount  of  provisional  callus  (Nature's 
splint)  depends  on  the  amount  of  motion  between  the 
fragments,  as  motion  causes  inflammation  and  inflamma- 
tion manufactures  new  material.  The  greater  the  range 
of  motion  allowed,  the  larger  the  amount  of  provisional 
callus.  In  a  well-adjusted  and  properly-dressed  fracture 
there  is  very  Httle  provisional  callus.  This  provisional 
callus  after  a  time  is  largely  absorbed  and  the  medullary 
canal  may  again  be  open  (requires  months  or  even  years). 
An  excessive  amount  of  provisional  callus  may  cause 
ossification  of  adjacent  tendons,  may  unite  the  radius 
to  the  ulna,  or  may  block  a  joint  from  opening  just  as  a 
stone  placed  in  a  door-crack  would  block  the  opening  of  the 
door.  Joints  may  be  entirely  abolished  by  provisional  callus. 
Fragments,  even  if  entirely  detached,  may  again  unite  with 
the  bone,  may  be  surrounded  by  callus  and  induce  no  symp- 
toms, or  may  lead  to  suppuration.  During  the  first  week 
after  the  fracture  the  clot  is  absorbed ;  at  the  beginning 
of  the  second  week  organization  begins ;  at  the  end  of  the 
21 


322  A   MANUAL    OF  SURGERY. 

third  week  ossification  is  begun,  and  is  completed  at  the  end 
of  the  eighth  or  ninth  week.  It  takes  about  one  year  to 
remove  the  temporary  callus.  If  callus  does  not  get  beyond 
the  fibrous  state,  there  is  that  form  of  ununited  fracture 
known  as  "  fibrous  union." 

Compound  fractures  without  much  destruction  or  bruising 
of  soft  parts,  if  treated  antiseptically,  become  at  once  simple 
fractures  and  unite  as  such.  If  the  wound  is  not  drained 
and  asepticized,  septic  inflammation  occurs,  pus  forms,  and 
union  by  granulation  is  the  best  that  can  be  obtained.  Com- 
pound fractures  by  direct  violence  will  not  heal  by  first  inten- 
tion because  of  the  extensive  loss  of  vitality  of  a  large  area 
of  the  soft  parts. 

Non-union  of  Fractures. — An  ununited  fracture  is  a  frac- 
ture in  which  the  fragments  are  not  held  together  by  bone. 
The  causes  are  local  and  constitutional.  The  local  causes 
are  (i)  want  of  approximation  of  fragments;  (2)  want  of 
rest ;  (3)  want  of  blood-supply  (as  seen  in  the  heads  of 
humerus  and  femur,  or  when  a  nutrient  artery  is  torn,  or 
when  a  thrombus  forms  in  a  vein  near  the  fracture);  (4)  de- 
fectiv^e  innervation;  and  (5)  bone-disease.  The  constitutional 
causes  are  debility,  scurvy,  Bright's  disease,  etc.  In  this  con- 
dition the  broken  ends  of  the  bone  are  rounded  off  and  the 
medullary  canal  in  each  fragment  is  closed  by  bone.  The 
fragments  may  not  be  held  together  by  any  material,  or  they 
may  be  held  by  very  thin  and  much  stretched  fibrous  tissue 
(inenibranous  union),  or  by  strong,  thick,  fibrous  tissue 
(ligamentous  or  fibrous  union).  When  the  ends  of  the 
bones  come  together,  are  held  by  a  fibrous  capsule,  and 
move  on  each  other,  there  is  presented  a  false  joint  or  pseud- 
arthrosis.  Such  a  joint  may  after  a  time  secrete  serous  fluid 
for  lubrication. 

Treatment  of  Fractures. — If  a  man  is  found  in  the 
street  injured,  further  injury  must  be  prevented  by  applying, 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      323 

after  cutting  off  the  clothing  over  the  fracture,  some  tem- 
porary support.  If  an  ambulance  or  patrol-wagon  cannot 
be  obtained,  move  the  patient  by  hand.  If  the  lower  ex- 
tremity be  involved,  an  improvised  stretcher  (a  board  or  a 
shutter)  is  placed  on  the  ground  beside  the  patient,  who  is 
placed  on  the  stretcher,  the  surgeon  lifting  the  injured  limb, 
and  the  patient  is  then  carried  to  the  hospital  and  carefully 
transferred  to  a  fracture-bed,  or,  if  taken  home,  to  a  small 
ordinary  bed,  a  board  being  placed  beneath  a  rather  hard  but 
even  mattress.  The  temporary  appliances  are  now  removed 
and  a  diagnosis  by  the  methods  before  given  is  proceeded 
with.  After  determining  the  injury  the  fragments  must  be 
adjusted.  This  should,  if  possible,  be  done  at  once,  because 
a  fracture  remaining  unreduced  may  become  compound,  the 
fragments  may  injure  important  structures,  and  they  are  sure 
to  cause  intense  pain.  Reduction  is  easily  effected  during 
shock,  as  the  muscles  are  in  a  state  of  relaxation.  If  there 
is  great  swelling,  reduction  may  be  impossible,  and  the  part 
must  then  be  supported  and  antiphlogistics,  sorbefacients, 
and  moderate  pressure  be  used,  avoiding  ice  and  tight  ban- 
daging, which  predispose  to  gangrene.  Set  the  fracture  at 
the  first  possible  moment.  Velpeau's  axiom  was  to  reduce 
fractures  at  once,  regardless  of  pain,  spasm,  or  inflammation, 
as  reduction  is  their  cure. 

If  the  patient  is  very  nervous,  if  the  pain  is  severe,  or  if 
rigid  muscles  antagonize  the  efforts,  then  reduce  the  fracture 
under  anaesthesia.  In  some  fractures  (as  those  of  the  clavicle) 
adjustment  is  effected  by  altering  the  position,  and  in  others 
(as  those  of  the  femur)  by  extension  and  counter-extension; 
in  some  by  tenotomy,  and  in  some  by  kneading,  bending, 
and  coaptation.  When  extension  is  employed,  always  en- 
deavor to  get  a  point  of  counter-extension.  The  extension 
is  to  be  made  on  the  broken  bone  (if  possible,  in  the  axis  of 
the  bone),  and  is  to  be  steady,  not  jerky  nor  violent.     In 


324  ^-i    MANUAL    OF  SURGERY. 

some  cases  complete  reduction  is  impossible.  This  may  be 
due  to  spasm,  to  swelling,  to  the  catching  of  soft  parts 
between  the  fragments,  to  the  existence  of  a  loose  fragment, 
to  locking,  or  to  impaction.  An  impaction  by  rotation  can 
generally  be  released,  but  it  is  sometimes  undesirable  to 
reduce  it.  If  the  fragments  cannot  be  adjusted  without  vio- 
lence, retain  them  in  the  best  attainable  position,  combat  the 
antagonistic  cause,  and  set  them  properly  as  soon  as  possible. 

After  adjusting  the  fragments  they  must  be  maintained 
in  position  by  some  retentive  apparatus.  Avoid  pressure 
over  joints  or  bony  prominences,  and  particularly  guard 
against  tight  or  improper  bandaging.  The  circulation  in 
the  fingers  or  the  toes  must  be  observed  as  an  index  of 
circulation  in  the  limb ;  hence  leave  these  digits  exposed. 
A  retentive  apparatus  must  prevent  the  re-occurrence  of  de- 
formity, and  not  be  itself  productive  of  pain  or  harm.  For 
the  first  few  days  after  a  simple  fracture  the  dressing  is  re- 
moved every  day,  to  make  sure  that  deformity  has  not  re- 
curred, and  if  it  docs  recur  the  fragments  must  at  once  be 
reset.  The  splints  should  be  padded  thoroughly,  especially 
when  over  joints  or  bony  prominences,  and  they  should,  if 
possible,  fix  the  joints  immediately  above  and  below  the 
break.     A  primary  roller  should  never  be  used. 

Some  surgeons  at  once  apply  an  immovable  dressing. 
This  proceeding  is  safe  in  simple  fractures  without  much 
displacement  or  soft-part  injury.  This  apparatus  is  used 
also  in  military  practice,  with  the  old  and  feeble  whom  we 
fear  to  put  to  bed,  with  the  young  who  are  very  restless,  and 
with  the  insane  or  the  delirious.  If,  however,  there  is  great 
deformity,  much  soft-part  injury,  or  marked  swelling,  im- 
movable dressings  may  induce  sloughing,  oedema,  gangrene, 
or  faulty  union.  In  the  above-named  cases  use  splints  for 
the  first  few  days ;  then,  if  it  is  desirable,  the  immovable 
dressing   can  be  applied.     It  is  dangerous  to   keep  old  or 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS       325 

feeble  persons  long  in  bed,  as  they  are  prone  to  develop 
bed-sores  and  hypostatic  pulmonary  congestion.  The  period 
for  the  artificial  retention  of  the  fracture  varies  with  the  seat 
of  the  fracture  and  the  age  and  the  condition  of  the  patient. 
Passive  motion  is  to  be  made  in  most  fractures  in  from 
two  to  three  weeks,  though  it  is  sometimes  made  earlier  to 
prevent  ankylosis. 

Prevention  and  Treatment  of  Complications. — If  the  soft 
parts  are  badly  contused,  try  to  prevent  sloughing  by  rest, 
relaxation,  and  lead-water  and  laudanum.  If  superficial 
sloughing  occurs,  treat  antiseptically,  remembering  that  a 
superficial  excoriation  may  admit  germs  which,  carried  by 
the  blood  or  lymph,  may  infect  the  bones.  If  a  slough  leads 
down  to  the  fracture,  treat  the  case  as  one  of  compound  frac- 
ture. If  there  be  great  blood-extravasation,  the  danger  is 
gangrene,  and  the  foot  of  the  bed  is  to  be  elevated,  or  the 
extremity,  to  which  splints  and  bandages  are  to  be  loosely 
applied,  is  to  be  raised ;  lead-water  and  laudanum  is  applied 
if  there  be  much  inflammation,  and  cotton-wool  and  hot 
bottles  if  the  surface  be  cold.  If  a  bleb  forms,  it  is  to  be 
opened  with  a  needle  and  dressed  antiseptically.  If  gangrene 
occurs,  treat  by  the  usual  rules.  BulLx  with  good  circula- 
tion do  not  mean  gangrene. 

CEdema  may  be  due  to  tight  bandaging.  If  it  is  due  to 
phlebitis,  there  is  danger  of  pulmonary  or  cerebral  embolism. 
In  these  cases  elevate  the  limb,  remove  all  constriction,  and 
employ  locally  tincture  of  iodine,  blue  ointment,  and  lead- 
water  and  laudanum,  and  internally  strouGf  stimulation.  In 
oedema  due  to  weak  circulation  or  venous  relaxation,  use 
daily  frictions  and  firm  bandaging.  If  the  fracture  involves  a 
joint,  carefully  adjust  the  fragments,  make  passive  motion 
early,  and  inform  the  patient  that  he  will  have  a  stiff  joint. 

A  dislocation  occurring  with  a  fracture  is  reduced  at  once 
if  possible.     To  do  this,  splint  the  limb  and  give  ether,  and 


326  A   MANUAL    OF  SURGERY. 

try  to  reduce  while  the  Hmb  is  managed  with  the  sphnt  as 
a  handle.  If  this  fails,  get  the  bones  in  the  best  possible 
position,  set  them,  await  union,  and  then  treat  the  unre- 
duced dislocation.  A  rupture  of  the  main  artery  of  the 
limb  presents  the  symptoms  of  absent  pulse  below  the  rup- 
ture, a  pulsating  tumor,  and  an  aneurysmal  thrill  and  bruit. 
This  condition  demands  that  the  surgeon  should  apply  an 
Esmarch  bandage,  cut  down  upon  the  tumor,  turn  out  the 
clot,  and  if  possible  ligate  each  end  of  the  vessel.  If  these 
measures  fail  or  if  gangrene  appears,  amputate  at  once, 
above  the  seat  of  the  fracture. 

Inflammation  is  to  be  treated  by  compression,  rest,  lead- 
water  and  laudanum,  and  later  by  a  50  per  cent,  ichthyol 
ointment.  Muscular  spasm  requires  morphia,  firm  bandag- 
ing, or  even  tenotomy.  Fat-embolism  is  treated  by  stimu- 
lants and  artificial  respiration.  Shock,  delirium  tremens, 
urinary  retention,  etc.  are  treated  according  to  the  ordinary 
rules  of  surgery. 

Treatment  of  Compound  Fractures. — It  must  first  be  de- 
cided, in  cases  of  compound  fracture,  if  amputation  is  neces- 
sary. Amputation  is  demanded  when  the  limb  is  completely 
crushed  or  pulpefied  through  its  entire  thickness;  when  ex- 
tensive pieces  of  skin  are  torn  off;  when  an  important  joint 
is  badly  splintered  ;  when  the  main  artery,  vein,  and  nerve 
are  torn  through  ;  and  when  there  is  violent  hemorrhage 
from  a  deep-seated  vessel.  What  is  to  be  done  is  to  some 
extent  determined  by  the  patient's  age  and  general  health. 
In  a  healthy  young  person,  if  in  doubt,  give  the  limb  the 
benefit  of  the  doubt  and  try  to  save  it :  if  the  artery  alone 
is  ruptured,  cut  down  upon  it  and  tie  both  ends  ;  if  the  nerve 
is  severed,  suture  it ;  if  a  joint  is  opened,  drain  and  asepticize. 
If  an  attempt  is  made  to  save  the  limb,  be  ready  at  any  time 
to  amputate  for  gangrene,  secondary  hemorrhage  (if  re-liga- 
tion  at  original  point  and  compression  high  up  fail),  extensive 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      327 

cellulitis,  and  profuse  and  prolonged  suppuration.^  When 
it  is  determined  to  try  to  save  the  limb,  the  part  must  be 
cleansed  thoroughly  by  the  antiseptic  method  (in  no  injuries 
is  this  more  important).  The  fragments  are  reduced,  resect- 
ing if  necessary,  and  are  usually  held  together  by  silver  wire, 
copper  wire,  or  catgut.  Thorough  through-and-through 
drainage  is  established  and  tubes  are  inserted.  The  ex- 
tremity is  put  in  a  proper  position,  the  damaged  area  and  its 
neighboring  parts  are  enveloped  in  corrosive-sublimate  gauze, 
plaster  is  at  once  applied  over  brackets  or  over  a  well-padded 
stick  of  wood,  and  in  the  plaster  a  trap-door  is  cut  before  it 
sets,  over  each  end  of,  and  around,  the  drainage-tube  (Fig.  47). 


Fig.  47. — Fenestrated  Plaster-of-Paris  Dressing  (Tiemann). 


These  trap-doors  are  covered  with  corrosive-sublimate  gauze 
which  is  held  in  place  by  a  roller.  The  drainage-tubes  are 
usually  removed,  if  suppuration  does  not  occur,  in  from 
forty-eight  to  seventy-two  hours.  The  wound  is  treated  as 
any  other  wound. 

Compound  fractures  may  be  followed  by  gangrene,  slough- 

1  See  Howard  Marsh  on  "Fractures"   in   Heath's  Dictionary  of  Pnittical 
Surgery. 


328  A    MANUAL    OF  SURGERY. 

ing,    periostitis,    sepsis,    osteo-myelitis,   necrosis,  etc.      The 
treatment  of  these  conditions  is  by  their  well-known  rules. 

Treatment  of  Delayed  Ujiion. — When  this  condition  exists, 
seek  for  a  cause  and  remove  it,  treating  constitutionally  if 
required,  and  thoroughly  immobilizing  the  parts  by  plaster. 
Orthopaedic  splints  may  be  of  value.  Use  of  the  limb 
while  splinted,  percussion  over  the  fracture,  and  rubbing  the 
fragments  together,  thus  in  each  case  producing  irritation, 
have  all  been  recommended.  Blistering  the  skin  with  iodine 
or  firing  it  has  been  employed.  If  the  case  be  very  long 
delayed,  break  the  bone  anew  and  put  it  up  in  plaster  as 
a  fresh  break.  If  these  means  fail,  irritate  by  subcutaneous 
drilling  or  scraping,  or,  better,  by  laying  open  the  parts 
and  then  drilling  and  scraping  at  many  places.  Leaving 
acupuncture-needles  in  for  days  is  approved  by  some,  and 
electro-puncture  is  advocated  by  others.  Old  cases  or  cases 
of  false  joint  must  be  treated  by  excision  of  the  bony  ends 
and  fibrous  tissue,  securing  the  fragments  together  by  peri- 
osteal sutures,  by  pins,  by  pins  and  plates,  by  ivory  pegs,  by 
screws,  by  silver  or  copper  wire,  or  by  chromicized  catgut. 
(See  Osteotomy^ 

Vicious  union  may  arise  from  a  failure  to  coaptate  the 
fragments,  from  a  recurrence  of  displacement  after  reduction, 
or  from  yielding  of  the  callus  after  the  splints  have  been 
removed.  If  angular  deformity  results  from  faulty  union, 
it  can  be  corrected  while  the  callus  is  soft.  If  the  callus 
has  become  hard,  the  bone  can  be  refractured.  If  faulty 
union  occurs  with  overriding,  an  osteotomy  can  be  per- 
formed. 

Special  Fractures  :  Nasal  Bones. — The  nasal  bones^  be- 
cause of  their  situation,  are  often  broken.  The  commonest 
site  of  fracture  is  through  the  lower  third,  where  the  bones 
are  thin  and  lack  support.  The  fracture  may  be  compound 
externally  or  internally.     The  cause  is  direct  violence.     Dis- 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      329 

placement  may  not  occur  at  all,  but  when  present  it  arises 
purely  from  force,  and  never  from  muscular  action,  no 
muscle  being  attached  to  these  bones.  If  the  force  is  from 
the  front,  the  nose  is  flattened;  if  from  the  side,  deflected 
and  depressed.  Displacement  is  soon  masked  by  swelling. 
Crepitus  can  sometimes  be  elicited  by  grasping  the  upper 
part  of  the  nose  with  the  fingers  of  one  hand  and  moving  it 
below-  from  side  to  side  with  those  of  the  other  hand.  Pre- 
ternatural mobility  is  valueless  as  a  sign,  because  of  the 
natural  mobility  of  the  cartilages.  Diagnosis  is  almost 
impossible  when  deformity  is  absent. 

The  comxplications  that  may  be  noted  are  cerebral  concus- 
sion, brain-symptoms  from  implication  of  the  frontal  bone  or 
cribriform  plate  of  the  ethmoid,  and  extension  of  fracture  to 
the  superior  maxillary  or  lachrymal  bones.  Emphysema  is 
common,  and  means  either  a  rent  in  the  mucous  membrane 
of  Schneider  or  a  crack  in  the  frontal  sinus.  Epistaxis  is 
usual,  and  is  separated  from  the  epistaxis  in  fractures  of  the 
base  of  the  skull  by  the  facts  that  the  bleeding  in  the  first 
condition  is  profuse,  is,  as  a  rule,  soon  checked,  and  is  not 
followed  by  an  ooze  of  cerebro-spinal  fluid,  whereas  in  the 
second  condition  it  is  profuse,  continued,  and  followed  by  a 
flow  of  cerebro-spinal  fluid.  Fracture  of  the  bony  septum 
occasionally  complicates  nasal  fractures,  and  deviation  of 
the  cartilaginous  septum  often  takes  place.  The  prognosis 
is  usually  good. 

Treatment. — When  there  is  no  displacement,  or  when  a 
displacement  does  not  tend  to  be  reproduced  after  reduction, 
use  lead-water  and  laudanum  for  a  few  days  if  swelling  exists, 
but  employ  no  retentive  apparatus  of  any  kind.  Order  the 
patient  not  to  blow  his  nose  for  ten  days  and  to  syringe  it  out 
daily  with  a  solution  of  bicarbonate  of  sodium.  If  deformity  be 
noted,  correct  it  at  once,  as  the  bones  soon  unite  in  deformity. 
If  the  attempts  at  reduction  are  very  painful  or  if  the  subject 


330 


A   MANUAL    OF  SURGERY. 


^-. 


Fig.  48. — Mason's  Pin. 


be  a  child,  a  woman,  or  a  nervous  man,  give  ether  or  spray 
the  interior  of  the  nose  with  a  4  per  cent,  solution  of  cocaine. 
Reduction  is  effected  by  a  grooved  director  in  the  nostril 

lifting  up  the  fragments,  and  the 
fingers  externally  moulding  them 
into  place,  or  by  a  rubber  dilator 
which  is  pushed  into  the  nose  and 
inflated  by  air  or  water.  If  mod- 
erate hemorrhage  is  found,  check 
it  with  cold ;  if  severe,  by  plug- 
ging. If  flattening  tends  to  recur, 
pass  a  Mason  pin  (Fig.  48)  just 
beneath  the  fragments,  through 
their  periosteum,  and  steady  them 
by  a  piece  of  rubber  externally 
caught  on  each  end  of  the  pin  or  by  figure-of-8  turns  with 
silk  around  the  ends.  Leave  the  pin  in  place  for  five 
days. 

If  a  lateral  deformity  tends  to  recur,  hold  a  compress 
over  the  fracture  or  fix  a  moulded-rubber  splint  over  the 
nose  by  a  piece  of  rubber  plaster  one  and  a  half  inches 
broad  and  long  enough  to  reach  well  across  the  face,  and 
use  compression  for  ten  days.  In  neither  of  the  above  cases 
is  the  nose  to  be  blown,  but  in  both  cases  it  is  to  be  syringed 
daily.  In  both  cases,  after  dressing,  if  the  swelling  be 
marked,  use  lead-water  and  laudanum.  In  fractures  ren- 
dered compound  by  tears  in  the  mucous  membrane,  irrigate 
with  corrosive-sublimate  solution,  holding  the  head  so  that 
the  solution  will  not  run  into  the  mouth  ;  wash  with  boiled 
water;  plug  with  iodoform  gauze  around  a  small  rubber 
catheter,  which  instrument  permits  nose-breathing  ;  carefully 
remove  the  gauze  daily  and  syringe.  In  fractures  compound 
externally,  dress  antiseptically  externally.  Fractures  of  the 
bony  septum,  if  showing  a  tendency  to  reproduction  of  de- 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      33 1 

formity,  require  packing  as  above  explained  or  the  use  of  a 
special  splint  (Fig.  49).  Fractures  of  the  nasal  cartilages  are 
to  be  pinned  in  place.  Fractures 
of  tlie  nose  are  entirely  united  in 
from  ten  to  twelve  days. 

Superior  Maxillary  Fractures. 

\  1,1  1  r  -1  u  •         Fig.  40. — Jones's  Nasal  Splint  i  Lentzi. 

— Although    a    fragile    bone    is  ^^    ^ 

rarely  broken  except  through  the  alveolar  border,  it  may 
be  broken  by  transmitted  force  from  blows  on  the  chin  or  on 
the  head  when  the  chin  is  fixed ;  but  direct  violence  is  the 
usual  cause,  and  the  wall  of  the  antrum  may  be  crushed  in. 
Comminution  is  the  rule,  and  the  injury  is  often  compound. 
These  fractures  induce  great  swelling,  pain,  and  inability  to 
chew ;  mobility  and  crepitus  may  be  detected.  Deformity 
is  due  to  the  breaking  force,  and  not  to  any  muscle. 
When  a  portion  of  the  alveolar  arch  is  fractured,  as  may 
occur  in  pulling  teeth,  the  fragment  is  depressed  backward, 
and  there  exist  irregularity  of  the  teeth  (some  of  which  may 
be  loosened)  and  inability  to  chew  food.  Fracture  of  the 
nasal  process  is  apt  to  injure  the  lachrymal  duct.  When 
the  antrum  is  broken  in  there  are  great  sinking  over  the 
fracture,  depression  of  the  malar  bone,  and  emphysema. 
Transverse  fracture  of  the  upper  part  of  the  body  of  the  bone 
may  cause  no  deformity.  The  force  sufficient  to  break  the 
superior  maxillary  bone  is  so  great  that  fractures  of  other 
bones  almost  certainly  occur,  and  concussion  of  the  brain 
not  infrequently  exists.  Injury  of  the  infraorbital  nerve  is 
not  unusual,  causing  pain,  numbness,  or  an  area  of  anaesthesia 
involving  one-half  of  the  upper  lip,  the  ala  of  the  nose,  and 
a  triangle  whose  base  is  one-half  the  upper  lip  and  whose 
apex  is  the  infraorbital  foramen.  There  is  also  loss  of 
sensation  in  the  gums  and  upper  teeth  of  the  injured  side. 
Fractures  oTthe  superior  maxillary  bone  occasionally  induce 
fierce  hemorrhage  from  branches  of  the  internal  maxillary 


332  A   MANUAL    OF  SURGERY. 

artery,  and  if  this  occurs,  watch  out  for  secondary  hemor- 
rhage (these  vessels  being  in  firm  canals). 

Treatment. — If  the  fracture  does  not  implicate  the  alveolus 
or  if  no  deformity  exists,  apply  no  apparatus,  but  feed  the 
patient  on  liquid  food  for  four  weeks.  Reduce  deformity,  if 
it  exists,  by  inserting  a  finger  in  the  mouth.  If  the  antrum 
is  broken  in,  put  the  thumb  in  the  mouth  and  push  the  malar 
bone  up  and  back.  In  certain  cases  of  deformity,  make  an 
incision  at  the  anterior  border  of  the  masseter  muscle,  insert 
a  tenaculum  or  aneurysm-needle,  and  pull  the  bone  into  place 
(Hamilton).  Loose  teeth  are  not  to  be  removed  :  they  are 
pushed  back  into  place  and  held  by  wiring  them  to  their 
firmer  neighbors.  Hemorrhage  is  arrested  by  cold  and 
pressure.  If  hemorrhage  is  dangerously  profuse  or  pro- 
longed, tie  the  carotid. 

If  the  line  of  the  teeth,  notwithstanding  the  wiring,  is  not 
regular,  mould  on  an  inter-dental  splint.  The  usual  splint 
for  the  upper  jaw  is  the  lower  jaw  held  firmly  against  it  by 
the  Gibson,  the  Barton,  or  the  four-tailed  bandage.  Every 
second  day  remove  the  bandage  and  wash  the  face  with 
ethereal  soap.  The  patient,  who  is  ordered  not  to  talk,  is  to 
live  on  liquid  food  administered  by  pouring  it  into  the  mouth 
back  of  the  last  molar  tooth  by  means  of  a  tube  or  a  feeding- 
cup.  Never  pull  a  tooth  to  get  a  space,  but  if  a  tooth  is  lost, 
utilize  its  space  for  this  purpose.  After  every  meal  wash 
out  the  mouth  with  chlorate-of-potash  or  boracic-acid  solu- 
tion to  prevent  foulness  and  the  digestive  disorders  it  may 
induce.  Leave  off  the  dressings  in  five  weeks,  and  let  the 
patient  gradually  return  to  ordinary  diet. 

In  fractures  compound  externally,  do  not  remove  frag- 
ments, antisepticize,  arrest  bleeding  as  far  as  possible  by 
ligature,  by  pressure,  or  by  plugging,  wire  the  fragments  if 
feasible,  dress  with  gauze,  and  wash  the  mouth  with  great 
frequency.     Fractures    compound    internally  are  treated  as 


SPLINTS. 


Plate 


I.  Fracture-box.  2.  Double  Inclined  Plane  Fracture-box.  3.  Jaw-cup  (unfolded).  4.  Jaw-cup 
(folded).  5.  Anterior  Angular  Splint.  6.  Internal  Angular  Splint.  7.  Bond  Splint.  8.  Shoulder-cap 
9.  Dupuytren  Splint  in  Pott's  Fracture.  10.  Agnew  Splint  for  Fracture  of  the  Metacarpus  11  Agnew 
Splint  for  Fracture  of  the  Patella.  ,2.  Agnew  Splint  applied.  13.  Strapping  the  Chest  in  Fractured 
Ribs.  14.  Extension  Apparatus  in  Fracture  of  the  Femur.  15,  16.  Adhesive  Strips  for  Extension 
Apparatus. 


DISEASES  AND   INJURIES    OF  BONES  AND  JOINTS.      333 

simple  fractures,  except  that  the  mouth  is  washed  more 
frequently. 

The  malar  bone  is  rarely  broken  alone.  Hamilton  says 
no  uncomplicated  case  is  on  record.  The  malar  is  a  strong 
bone  resting  on  a  fragile  support,  and  hence  it  can  be  used 
as  a  wedge  to  break  other  bones  and  yet  itself  be  unfrac- 
tured.  The  caKsc  of  fracture  is  violent  direct  force.  A 
fracture  of  the  orbital  surface  of  this  bone  causes  subcon- 
junctival hemorrhage  like  that  encountered  in  fracture  of 
the  base  of  the  skull.  Protrusion  of  the  eye  may  result 
either  from  hemorrhage  or  from  crushing  in  of  the  malar 
bone.     Chewing  is  apt  to  cause  pain. 

Trcatmoit. — If  no  deformity  exists,  there  is  practically 
nothing  to  be  done.  If  deformity  exists,  try  to  correct  it  as 
in  fractures  of  the  superior  maxillary.  As  these  cases  are 
almost  invariably  complicated  by  breaks  of  the  upper  jaw, 
they  are  treated  in  the  same  manner  as  the  latter  injury. 
The  union  is   complete   in   three   weeks. 

Fracture  of  the  zyg-omatic  arch  is  very  rare.  The 
causes  are  (i)  direct  violence;  (2)  indirect  force  (from  depres- 
sion of  the  malar) ;  and  (3)  forcing  of  foreign  bodies  through 
the  mouth.  Direct  violence  causes  inward  displacement,  and 
indirect  force  causes  outward  displacement.  The  symptoms 
are  pain,  ecchymosis,  swelling,  displacement,  and  difficulty 
in  moving  the  jaw  (because  of  injury  to  the  masseter). 

Trcatincnt. — In  simple  fracture,  give  ether  and  try  to  push 
the  arch  in  place.  Make  no  incision,  as  depression  will  do 
no  harm  and  the  functions  of  the  jaw  will  be  restored. 
Dress  with  compress,  adhesive  strips,  and  crossed  bandage 
of  the  angle  of  the  jaw  (PI.  10,  Fig.  i).  Union  will  take 
place  in  three  weeks. 

Fractures  of  the  inferior  maxillary  bone  may,  and  most 
usually  do,  affect  the  body,  although  they  occasionally  occur 
in  the  rami.    Any  part  of  the  body  may  be  fractured,  the  most 


334  ^^   MANUAL    OF  SURGERY. 

usual  seat  being  near  the  canine  tooth  or  a  little  external  to 
the  symphysis  (Pick).  A  portion  of  alveolus  maybe  broken 
off  In  fractures  of  the  ramus  either  the  angle,  the  condyloid 
neck,  or  the  coronoid  process  may  be  broken.  In  fractures 
of  the  body  the  posterior  fragment  generally  overrides  the 
anterior.  Fractures  of  the  lower  jaw  are  often  multiple  and 
are  almost  always  compound,  because  the  oral  mucous  mem- 
brane and  alveolar  periosteum  are  torn.  The  cause  is  usually 
direct  violence.  Indirect  violence  (lateral  pressure)  may  frac- 
ture the  body  anteriorly.  Fractures  near  the  angle  are 
always  due  to  direct  violence.  Indirect  violence  may  frac- 
ture the  condyle  (falls  on  the  chin),  and  so  may  direct 
violence.  Fractures  of  the  coronoid  are  very  rare,  and  they 
arise  from  great  direct  violence  (usually  gunshot  wound  or 
some  other  penetrating  force). 

Symptoms. — In  fracture  of  the  body  preternatural  mobility 
and  crepitus  generally  exist.  There  is  bleeding  because  of 
laceration  of  the  gums ;  saliva  dribbles  constantly ;  the  jaw 
is  supported  by  the  hand  ;  great  pain  exists  (possibly  from 
injury  of  the  nerve) ;  and  deformity  is  present,  shown  by 
inequality  of  the  teeth  if  fracture  is  anterior  to  masseter.  the 
anterior  fragment  going  downward  and  backward  and  the 
posterior  fragment  going  upward  and  forward.  The  down- 
ward displacement  is  due  to  muscular  action  (action  of  the 
digastric,  geniohyoid,  and  genio-hyoglossus).  The  backward 
displacement  is  due  to  the  violence.  The  temporal  muscle 
draws  the  posterior  fragment  up  and  to  the  front.  In  frac- 
ture of  the  neck  of  the  condyle  the  jaw  is  drawn  toward  the 
injured  side  and  the  condyle  goes  inward  and  forward  by  the 
action  of  the  external  pterygoid.  In  fracture  of  the  coronoid 
process  the  temporal  pulls  the  small  fragment  up. 

Complications. — The  complications  are — digestive  disorders 
and  diarrhoea  from  swallowing  foul  discharges;  loosening 
of  the  teeth ;  loosened  teeth  between  fragments ;  bleeding 


DISEASES  AND   INJURIES    OE  BONES  AND  JOINIS.      335 

(usually  only  oozing  from  the  gums,  but  there  may  be  hem- 
orrhage from  the  inferior  dental) ;  and  suppuration.  Necrosis 
may  follow  these  fractures. 

Treatment. — Remove  a  tooth  if  between  fragments,  but 
replace  it  in  its  socket  after  reducing  the  fracture.  Correct 
deformity.  Push  in  loose  teeth  and  put  back  detached  ones. 
Wash  out  the  mouth  with  hot  water  to  clean  it  and  to  check 
bleeding.  If  bleeding  is  very  severe,  compress  the  carotid  for 
a  time.  The  fracture  can  be  dressed  with  a  pad  of  lint  over 
the  chin  and  a  four-tailed  bandage  ;  or  put  on  a  splint  of  paste- 
board, felt,  or  gutta-percha  (cut  as  shown  on  PI.  7,  Figs.  3,  4) 
moulded  to  the  part,  padded  with  cotton,  and  held  in  place 
by  a  Barton  or  a  Gibson  bandage  (PI.  10,  Figs.  2,  5).  If  appo- 
sition of  the  fragments  cannot  be  maintained  by  the  above 
methods,  fasten  the  teeth  together  with  wire,  wire  the  frag- 
ments themselves  together,  or  employ  inter-dental  splints. 
The  patient  is  to  be  fed  on  liquid  food  (see  Fracture  of  the 
Upper  Jazi\  p.  332),  the  mouth  is  to  be  washed  out  frequently, 
and  the  dressings  are  to  be  changed  every  second  day.  The 
union  is  complete  in  five  weeks.  Though  these  fractures 
are  usually  compound,  they  do  not  endanger  life.  If  they 
are  compound,  wash  the  mouth  often  with  a  solution  of 
boracic  acid  or  of  chlorate  of  potash. 

Fractures  of  the  Hyoid  Bone. — These  fractures  are  rare 
injuries,  and  are  caused  by  hanging,  by  the  throat  being 
grasped  by  an  antagonist,  and  by  falls  in  which  the  neck 
strikes  some  obstacle.  If  the  bone  breaks  by  throttling,  it  is 
its  body  which  fractures  (indirect  force).  Fractures  by  mus- 
cular action  are  most  unusual. 

Symptoms. — The  symptoms  are — a  sensation  of  something 
breaking ;  bleeding  from  the  mouth  if  the  mucous  mem- 
brane be  lacerated ;  pain,  which  is  worse  on  opening  the 
jaws  or  on  moving  the  head  or  tongue ;  difficulty  in  swal- 
lowing (dysphagia) ;  muffled,  hoarse,  or  absent  voice ;  swell- 


336  A    MANUAL    OF  SURGERY. 

ing,  and  frequently  ecchymosis,  of  the  neck.  There  are 
observed  occasionally,  though  rarely,  harsh  cough  and  dysp- 
noea, irregularity  of  bony  contour,  and  crepitus.  Always 
look  into  the  mouth  and  see  if  there  can  be  detected  mucous 
ecchymosis  or  laceration  or  projection  of  a  bony  fragment. 
The  displacement  is  due  to  the  middle  constrictor  of  the 
pharynx   contracting.     This  fracture   may  destroy  life. 

Treatment. — For  dyspnoea  be  ready  to  perform  trache- 
otomy at  a  moment's  notice.  CEdema  of  the  glottis  is  a 
great  danger.  Try  to  restore  the  fragments  with  one  hand 
externally  and  with  a  finger  in  the  mouth.  Put  the  patient 
to  bed  and  have  him  lie  back  upon  a  firm  rest  so  that  his 
shoulders  are  elevated.  His  head  is  to  be  thrown  between 
extension  and  flexion,  a  pasteboard  splint  or  collar  is  moulded 
on  the  neck,  and  a  bandage  is  applied  around  forehead,  neck, 
and  shoulders  to  keep  the  head  immobile.  The  patient  must 
not  utter  a  word  for  a  week ;  he  must  at  first  be  fed  by 
enemata,  and  then  for  some  time  on  liquid  diet  which  is 
given  through  a  tube  early  in  the  case.  Endeavor  to  con- 
trol the  cough  by  opiates.  A  fractured  hyoid  bone  requires 
about  four  weeks  to  unite. 

Fracture  of  laryngeal  cartilages  is  caused  by  direct 
violence,  as  throttling,  blows,  or  kicks.  It  is  rare  in  young 
persons,  and  is  commonest  when  the  cartilages  have  begun 
to  ossify.  It  is  a  very  grave  injury  (80  per  cent,  die),  death 
arising  from  obstruction  to  the  entrance  of  air. 

Symptoms. — The  symptoms,  which  are  severe,  are  pain, 
aggravated  by  attempts  at  swallowing  or  speaking  ;  swelling, 
ecchymosis  it  may  be,  and  emphysema  of  the  neck  ;  cough  ; 
aphonia  ;  intense  dyspnoea  ;  and  bloody  expectoration  if  the 
mucous  membrane  is  ruptured.  There  can  be  detected  in- 
equality of  outline  (flattening  or  projection)  and  perhaps 
moist  crepitus.  The  usual  seat  of  the  injury  is  the  thyroid 
cartilage. 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      337 

Treatment. — Cases  without  dyspnoea  require  quiet,  avoid- 
ance of  all  talking,  feeding  with  a  stomach-tube,  compresses 
and  adhesive  strips  over  the  fracture,  remedies  to  quiet 
cough,  and  a  readiness  to  operate  at  any  moment.  In  most 
cases  dyspnoea  exists,  due  to  projection  of  the  fragments  or 
submucous  extravasation.  When  there  is  dyspnoea,  emphy- 
sema, or  spitting  of  blood,  at  once  practise  intubation  (p.  592), 
or,  if  unable  to  do  this,  open  the  larynx  or  trachea  below  the 
seat  of  fracture.  If  laryngotomy  or  tracheotomy  is  done, 
try  and  restore  displaced  fragments.  If  the  fragments  will 
not  stay  reduced,  introduce  a  Trendelenburg  canula  or  a 
tracheotomy-tube  around  which  gauze  is  packed.  Take  out 
the  packing  in  four  days,  and  remove  the  tube  as  soon  as 
the  patient  breathes  well,  when  the  opening  is  allowed  to 
close.  In  these  fractures  feed  with  a  stomach-tube  and  keep 
the  patient  absolutely  quiet.  Union  takes  place  in  four 
weeks. 

Fracture  of  the  Ribs. — The  ribs,  owing  to  their  shape, 
elasticity,  and  mode  of  attachment,  readily  bend  and  as 
readily  recover  their  shape,  thus  standing  considerable  force 
without  breaking.  Notwithstanding  these  facts,  the  situation 
of  the  ribs  so  exposes  them  that  in  sixteen  per  cent,  of  all 
cases  of  fractures  noted  by  Gurth  these  bones  were  involved. 
In  children  this  injury  is  rare  and  is  most  usually  incom- 
plete ;  it  is  common  in  adults  and  the  aged,  and  in  them  is 
generally  complete.  It  is  more  frequent  among  men  than 
among  women.  The  ribs  most  commonly  broken  are  from 
the  fifth  to  the  ninth,  the  seventh  being  the  most  usual 
sufferer.  The  eleventh  and  twelfth  ribs  are  seldom  broken. 
A  rib  ma}'  be  broken  in  several  places,  and  several  ribs  are 
often  broken  at  the  same  time.  These  fractures  may  be 
compound  either  through  the  skin  or  through  the  pleura, 
a  damaged  lung  permitting  pneumothorax ;  but  compound 
fractures  are  very  rare  except  from  bullet-wounds. 
22 


338  A   MANUAL    OF  SURGERY. 

Causes. — Direct  force,  as  buffer  accidents,  blows  with 
heavy  instruments,  or  being  jumped  on  while  recumbent, 
may  produce  these  injuries.  A  fracture  from  direct  violence 
occurs  at  the  point  struck,  and  the  ends,  projecting  inward, 
are  apt  to  damage  the  viscera.  Indirect  force,  as  great  pres- 
sure or  blows  which  exaggerate  the  natural  bony  curves, 
tends  to  produce  fractures  near  the  middle  of  the  ribs  or  in 
front  of  their  angles  and  to  force  the  ends  outward.  A  number 
of  ribs  are  apt  to  be  broken.  Muscular  action,  as  in  cough- 
ing or  parturition,  occasionally,  but  very  rarely,  is  a  cause. 

Symptoms. — In  connection  with  the  history  of  the  accident 
the  symptoms  are — acute  localized  pain  (a  stitch)  on  breathing, 
increased  by  pressure  over  the  injury,  pressure  backward  over 
the  sternum,  cough,  and  forcible  inspiration  or  expiration ; 
respiration  is  largely  diaphragmatic,  the  patient  endeavoring 
to  immobilize  the  injured  side;  cough  is  frequent  and  is  sup- 
pressed because  of  pain.  Crepitus  is  often  but  not  invariably 
found.  It  is  sought,  first,  by  resting  the  palm  over  the  seat 
of  pain  while  the  patient  takes  long  breaths ;  second,  by 
placing  a  thumb  before  and  behind  the  seat  of  pain  and 
making  alternate  pressure  ;  and  third,  by  auscultation.  It 
should  be  remembered  that  incomplete  fractures  are  the  rule 
in  children  ;  hence  in  them  do  not  expect  crepitus.  Deform- 
ity is  usually  trivial  unless  several  ribs  are  broken,  because 
shortening  cannot  occur  and  the  intercostal  attachments 
prevent  vertical  displacement.  Preternatural  mobility  may 
occasionally  be  elicited,  when  the  region  is  not  deeply  cov- 
ered with  muscles,  by  pressing  on  one  side  of  the  supposed 
break  and  observing  that  a  part  of,  and  not  the  entire,  rib 
moves.  Cellular  emphysema  without  a  surface-wound  is 
proof  of  rib-fracture.  Bloody  expectoration  and  emphysema 
mean  injury  of  the  lung.  A  simple  uncomplicated  case  in 
a  young  person  gives  a  good  prognosis. 

The  complications  are — additional  injury,  making  the  frac- 


DISEASES  AND   INJURIES   Of  BONES  AND  JOINTS.      339 

ture  externally  or  internally  compound  ;  laceration  of  pleura, 
pericardium,  heart,  lung,  diaphragm,  liver,  spleen,  or  colon  ; 
rupture  of  an  intercostal  artery;  haemothorax ;  cellular  em- 
physema ;  pulmonary  emphysema ;  pneumothorax  and  pyo- 
thorax;  traumatic  pleurisy;  pneumonia;  bronchitis;  con- 
gestion or  oedema  of  the  lungs. 

Treatment. — In  an  uncomplicated  case  the  patient  is  not 
put  to  bed,  as  breathing  is  easier  when  erect  than  when 
recumbent.  Angular  displacement  outward  is  corrected  by 
direct  pressure.  Displacement  inward  is  soon  corrected,  as 
a  rule,  by  the  expansion  of  ordinary  respiratory  action,  but 
if  it  is  not  thus  corrected,  etherize,  the  deep  breathing  of  the 
anaesthetic  state  almost  always  succeeding.  If  ether  fails 
and  dangerous  symptoms  come  on,  incise  under  strict  anti- 
septic guardianship,  elevate,  and  drain. 

After  correcting  any  existing  deformity,  immobilize  the 
injured  side.  Direct  the  patient  to  raise  his  arms  above  his 
head,  to  empty  his  chest  by  a  forced  expiration,  and  to  keep 
it  empty  until  a  piece  of  rubber  plaster  (two  inches  wide)  is 
forcibly  applied  seven  or  eight  inches  below  the  fracture  and 
reaching  from  the  spine  to  the  sternum.  The  patient  is  now 
allowed  to  take  a  breath  and  is  directed  to  empty  the  chest 
again,  another  piece  of  plaster  being  applied,  covering  the 
upper  two-thirds  of  the  width  of  the  previous  strip.  This 
process  is  continued  until  the  side  is  strapped  well  above 
and  well  below  the  fracture  (PI.  7,  Fig.  13).  Over  the  plaster 
light  turns  of  an  inelastic  spiral  bandage  are  carried,  or  pref- 
erablv  a  figure-of-8  bandage  of  the  chest,  the  turns  crossing 
over  the  seat  of  injury.  About  once  a  week  the  plaster  is 
removed  and  fresh  pieces  applied  after  rubbing  off  the  chest 
with  soap  liniment,  drying,  and  anointing  excoriations  with  an 
ointment  of  oxide  of  zinc.  The  dressing  is  worn  for  three 
or  four  weeks.  The  patient  avoids  cold,  damp,  and  draughts. 
The  diet  is  to  be  nutritious  but  non-stimulating,  and   any 


340  A    MANUAL    OF  SURGERY. 

cough  is  at  once  attacked  by  opiates  and  expectorants.  A 
person  with  this  injury  who  has  reached  the  age  of  sixty 
must  take  stimukuit  expectorants  (ammonii  carb.,  grs.  x,  in 
infus.  senegae,  5ss,  t.  in  d.)  or  employ  a  steam-tent  several 
times  a  day.  The  old  method  of  treatment,  in  which  the 
chest  was  included  in  a  forcibly-applied  broad  rib  roller,  is 
not  to  be  used  except  as  a  temporary  expedient;  it  com- 
presses the  entire  chest,  causes  pain  and  dyspnoea,  and  tends 
to  loosen  and  slip. 

Fracture  of  the  ribs  complicated  with  visceral  injury  is 
highly  dangerous,  and  requires  confinement  to  bed.  The 
treatment  is  that  of  the  visceral  injury.  If  there  be  bloody 
expectoration,  apply  adhesive  strips  as  above  indicated,  put 
the  patient  to  bed  reclining  on  a  bed-rest,  keep  him  quiet, 
subdue  the  circulation,  and  employ  opium,  diaphoretics, 
and  expectorants  (a  good  mixture  consists  of  squill,  ipecac, 
ammonium  acetate,  and  chloroform  ;  opium  is  given  sepa- 
rately). Inflammations  of  the  lung  or  the  pleura,  fortunately, 
are  apt  to  be  localized,  and  are  treated  as  are  ordinary  in- 
flammations of  these  parts.  In  laceration  of  an  intercostal 
artery,  incise  and  try  to  ligate ;  if  unable  to  ligate,  resect 
a  rib  and  apply  a  ligature.  If  the  signs  point  to  internal 
bleeding,  resect  a  rib,  search  for  the  bleeding  point,  and 
ligate.  Emphysema  usually  soon  disappears,  but  if  it  does 
not,  open  the  cellular  tissue,  dress  antiseptically,  and  employ 
pressure.  When  there  arises  a  sudden  attack  of  dyspnoea, 
which  is  prone  to  happen  in  these  cases,  and  in  which  there 
are  a  blue  face  and  a  laboring  pulse  and  suffocation  seems 
imminent,  bleed  the  patient  almost  to  syncope. 

Fracture  of  the  costal  cartilages  is  not  a  common 
occurrence,  even  in  the  aged.  Such  fractures  occur  either 
through  the  cartilages  or  through  their  points  of  junction 
with  the  ribs.  These  injuries  generally  arise  from  direct 
violence,  the  cartilage  of  the  eighth  rib  being  most  prone 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      34 1 

to  suffer.  Indirect  force  (such  as  a  blow  upon  the  shoulder) 
is  occasionally  the  cause,  but  when  it  is  the  cause  some 
other  injury  is  apt  to  be  noted.  Muscular  action  is  a  pos- 
sible cause. 

Symptoms. — Displacement  is  often  absent,  but  if  present  it 
is  forward  or  backward  of  either  fragment,  and  is  due  chiefly 
to  the  force  of  the  injury,  but  partly,  it  may  be,  to  muscular 
action:  When  displacement  is  absent  crepitus  will  not  often 
be  found  ;  in  fact,  crepitus  is  usually  absent  in  these  injuries. 
Localized  pain,  swelling,  and  ecchymosis  are  noted.  Preter- 
natural mobility  may  or  may  not  be  detected.  Union  by 
bone  is  to  be  expected. 

Treatment. — If  displacement  exists,  try  to  reduce  it.  If 
the  fragment  is  displaced  backward,  reduce  by  deep  inspira- 
tions ;  if  the  fragment  is  displaced  forward,  reduce  by  pull- 
ing back  the  shoulders.  In  this  attempt  failure  is  the  rule, 
and  the  surgeon  should  then  adopt  Malgaigne's  expedient 
of  applying  a  truss  over  the  projection  for  a  day  or  two. 
Dress  and  treat  the  case  as  if  a  rib  were  broken,  removing 
the  dressings  in  four  weeks. 

Fracture  of  the  Sternum. — The  sternum  may  be  broken, 
along  with  the  ribs  and  spine,  from  great  violence.  Frac- 
tures of  the  sternum  alone  are  infrequent,  because  the  bone 
rests  on  a  spring-bed  of  ribs.  Fractures  of  the  sternum  may 
be  simple  or  compound,  complete  or  incomplete,  single  or 
multiple.  The  most  usual  injury  is  a  simple  transverse  frac- 
ture at  or  near  the  gladio-manubrial  junction,  at  which  point 
dislocation  may  also  occur.  Both  fracture  and  separation 
of  the  ensiform  cartilage  are  very  rare.  The  sternum  may 
be  broken  along  with  the  ribs  or  clavicle. 

Causes. — The  causes  of  fracture  of  the  sternum  are — 
direct  force,  as  by  falls  of  embankments  or  of  walls,  by  car- 
crushes,  or  by  the  passing  of  a  cart-wheel  over  the  body; 
indirect  force,  as  by  falls  upon  the  head,  thus  driving  the 


342  A   MANUAL    OF  SURGERY. 

chin  against  the  chest;  by  falls  upon  the  feet,  the  buttocks, 
or  the  shoulder;  by  forced  flexion  or  extension  of  the  body 
over  an  edge  or  angle  (as  may  occur  during  labor-pains). 

Symptoms. — In  fracture  of  the  sternum  displacement  is  not 
always  present,  but  when  it  docs  occur  the  lower  fragment 
is  apt  to  go  forward ;  displacement  may,  however,  be  trans- 
verse or  angular,  or  there  may  be  overriding.  The  posterior 
periosteum,  which  rarely  tears,  limits  displacement,  but  some 
deformity  can,  as  a  rule,  be  detected.  The  history  of  the 
nature  of  the  accident  has  a  valuable  bearing  upon  the  ques- 
tion of  diagnosis.  The  position  assumed  by  the  patient  is 
with  the  head  and  body  bent  forward,  as  attempts  to  straighten 
up  cause  much  suffering.  There  is  fixed  and  localized  pain, 
increased  by  deep  respiratory  action,  by  body-movements,  or 
by  cough.  Crepitus  is  sought  for  by  auscultation  and  by 
placing  the  hand  over  the  injury  and  directing  the  patient  to 
make  quick  respirations.  Mobility  ma}^  become  manifest  on 
external  pressure,  during  respiration,  or  while  attempts  are 
being  made  to  bring  the  body  erect.  Respiration  in  these 
cases  is  usually  much  interfered  with.  It  is  not  important  to 
separate  diastasis  from  fracture. 

Complications. — Other  fractures  generally  complicate  frac- 
ture of  the  sternum,  and  laceration  of  the  pleura  or  peri- 
cardium and  hemorrhage  into  the  anterior  mediastinum 
may  exist.  Abscess  of  the  mediastinum  and  necrosis  of 
the  sternum  may  appear  as  late  consequences.  The  prog- 
nosis is  good  in  uncomplicated  cases. 

Treatment. — The  deformity  attending  fracture  of  the  ster- 
num is  to  be  corrected,  if  possible,  by  external  pressure. 
If  overriding  is  found,  effect  reduction  by  bending  the  body 
back  over  a  firm  pillow  and  ordering  deep  respiration  ;  if 
this  method  fails,  give  ether  and  then  bend  the  patient  back. 
The  deformity,  if  reduced,  tends  to  recur,  but  the  bones 
unite  well   in   deformity  and   no   great  harm  results.     The 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      343 

fragments  should  not  be  cut  down  on  or  hooked  up  unless 
there  be  internal  injury.  After  reducing  the  deformity, 
cover  the  front  of  the  chest  with  adhesive  strips  extending 
laterally  from  one  axillary  line  to  the  other  and  vertically 
from  well  above  the  fracture  down  to  the  ensiform  cartilage. 
Place  over  this  covering  an  anterior  figure-of-8  of  the  chest. 
In  some  cases,  where  deformity  recurs  after  reduction,  a  cir- 
cular JDandage  of  the  chest  is  applied  and  the  shoulders  are 
pulled  strongly  back  with  a  posterior  figure-of-8  bandage. 
The  plaster  is  to  be  renewed  once  a  week. 

Some  surgeons  treat  these  cases  by  means  of  a  large 
compress  held  by  adhesive  plaster  and  a  broad  tight  roller. 
The  patient,  however  dressed,  is  put  to  bed  and  reposes 
erect  or  semi-erect  on  a  bed-rest.  This  position  favors  easy 
respiration  and  antagonizes  the  tendency  to  displacement. 
The  diet  should  be  light,  nutritious,  and  non-stimulating. 
The  patient  is  convalescent  in  four  weeks,  and  the  plaster 
is  permanently  taken  off  in  fiv^e  weeks.  When  the  ensiform 
cartilage  is  so  bent  in  as  to  cause  intense  pain  or  to  injure 
the  stomach,  it  should  be  incised  and  resected.  QEdema  of 
the  skin  and  fever,  if  they  appear,  indicate  pus,  in  which  case 
an  incision  is  made  at  the  edge  of  the  sternum  and  the  pus- 
cavity  is  irrigated,  drained,  and  dressed  antiseptically. 

Fractures  of  the  Pelvis, — In  some  of  the  indicated  frac- 
tures serious  injury  of  the  pelvic  contents  is  apt  to  be  found. 

Fracture  of  the  False  Pelvis, — Fractures  of  this  region 
are  seldom  dangerous  unless  comminuted.  There  ma^'  be 
fracture  of  the  iliac  crest  or  of  the  anterior  superior  spine, 
or  the  line  of  fracture  may  traverse  the  entire  length  of  the 
flanged-out  ilium,  or  the  bone  may  be  comminuted  with  the 
association  of  grave  visceral  damage.  The  anterior  superior 
and  posterior  superior  spines  may  be  broken  off. 

Causes. — ^The  cause  of  fracture  of  the  false  pelvis  is  gen- 
erally violent  direct  force,  as  the  passage  of  a  wagon-wheel, 


344  ^   MANUAL    OF  SURGERY. 

the  fall  of  a  wall,  the  kick  of  a  mule,  or  the  force  of  car- 
crushes.  Violent  contraction  of  the  rectus  muscle  may  tear 
off  the  anterior  inferior  spine  of  the  ilium. 

SyinptoDis. — In  fracture  of  the  false  pelvis  the  history  of 
violent  force  is  noted.  The  patient  leans  toward  the  injured 
side.  Pain  exists,  which  is  aggravated  by  movements  (par- 
ticularly by  bending  forward),  by  coughing,  or  by  straining  to 
empty  the  bowels  or  the  bladder.  Ecchymosis  and  swelling 
are  manifest.  Crepitus  and  preternatural  mobility  are  de- 
tected by  moving  the  crest.  Deformity  is  very  rarely  present. 
Cases  uncomplicated  by  visceral  injury  make  good  recoveries. 

Complications. — The  fracture  may  be,  but  rarely  is,  com- 
pound, as  the  parts  are  well  protected  with  muscles.  The 
colon  may  be  injured  when  comminution  has  taken  place. 

Treatment.^ — In  treating  fracture  of  the  false  pelvis,  put 
the  patient  on  a  fracture-bed,  raise  the  shoulders,  and  put  a 
binder  about  the  pelvis,  or  encase  the  pelvis  with  broad  pieces 
of  rubber  plaster,  or  employ  the  belt  or  girdle.  Place  the 
knees  over  two  pillows  so  as  to  semiflex  the  legs  and  thighs, 
and  tie  the  knees  together.  To  restrain  thigh-movements  it 
may  be  necessary  to  encase  a  restless  patient  with  splints  or 
bind  him  to  sand-bags.  If  the  binder  displaces  the  fragments 
or  causes  pain,  abandon  it  and  trust  to  position.  The  dress- 
ings can  be  removed  in  six  weeks,  and  the  patient  is  allowed 
to  get  up  in  eight  weeks.  In  compound  fractures  of  the  false 
pelvis,  asepticize,  drain  and  dress,  put  on  a  binder,  and  direct 
the  same  position  to  be  maintained  as  for  simple  fractures. 

Fractures  of  the  True  Pelvis. — The  most  usual  seat  of 
these  fractures  is  through  the  obturator  foramen,  the  ascend- 
ing ischial  and  horizontal  pubic  rami  being  broken.  A  frac- 
ture may  occur  near  the  symphysis  pubis,  the  symphysis 
may  be  separated,  a  break  may  run  near  to  or  into  the  sacro- 
iliac joint,  the  same  fracture  may  occur  on  each  side  of  the 
body  of  the  pubis,  and  the  fracture  may  be  multiple.     Frac- 


DISEASES  AXD   INJURIES    OF  BOAES  AXD  JOINTS.      345 

tures  of  the  acetabulum  and  of  the  tuberosit}'  of  the  ischium 
may  occur.  Before  the  seventeenth  year  the  innominate 
bone  may  be  broken  into  its  three  anatomical  segments. 
These  injuries  are  highly  dangerous  because  of  the  damage 
which  is  apt  to  be  inflicted  on  the  pelvic  contents.  There 
may  be  rupture  of  the  bladder  or  membranous  urethra 
and  injury  of  the  vagina,  the  rectum,  the  uterus,  or  the 
small,  gut.  The  cansc  of  pelvic  fracture  is  violent  force, 
direct  or  indirect.  Front  force  tends  to  produce  direct,  and 
side  force  indirect,  fracture. 

Syniptouis. — In  pelvic  fracture  there  is  a  history  of  violent 
force.  There  are  great  shock,  ecchymosis  which  is  possibly 
linear,  swelling,  and  intense  pain  increased  by  attempts  at 
motion,  coughing,  and  straining.  There  is  also  inability  to 
sit  or  to  stand.  Mobility  becomes  obvious  on  grasping  an 
ilium  in  each  hand  and  moving  them.  Crepitus  may  be 
noticed  by  this  manoeuvre  or  by  moving  an  ilium  with  one 
hand,  a  finger  of  the  other  hand  being  inserted  in  the  rectum 
or  in  the  vagina.  In  making  movements  for  diagnostic  pur- 
poses, be  very  gentle,  as  rough  manipulation  permits  of  injury 
by  sharp  fragments.  There  may  be  doubt  as  to  whether  crepi- 
tus is  to  be  referred  to  pelvic  fracture  or  to  fracture  of  the 
neck  of  the  femur ;  in  this  case  follow  the  rule  of  Mr.  John 
Wood  •}  "  The  surgeon  grasps  the  femur  with  one  hand  and 
places  the  other  firmly  upon  the  anterior  superior  iliac  spine 
or  crest  or  upon  the  pubes ;  then,  on  moving  the  femur  and 
abducting  it  freely,  if  a  crepitus  be  detected,  it  will  be  felt 
the  more  distinctly  by  that  hand  which  rests  on  or  grasps 
the  fractured  bone." 

Injury  of  the  bladder  or  urethra  is  made  manifest  by 
retention  of  urine,  extravasation  of  urine,  hematuria,  etc. 
Bleeding  from  the  vagina  or  the  rectum  points  to  a  lacera- 
tion of  the  part  by  a  fragment.     Intestinal   injury   induces 

'^lancet,  1865,  vol.  ii.  p.  347. 


34^  A    MANUAL    OF  SURGERY. 

septic  peritonitis.  Fractures  of  the  brim  of  the  acetabulum 
permit  dorsal  dislocation  of  the  femur  to  occur,  which  dis- 
location will  not  remain  reduced.  The  acetabulum  may  be 
broken  by  falls  upon  the  feet,  and  when  its  base  is  broken 
the  injury  can  only  be  guessed  at  if  displacement  does  not 
take  place.  If  the  head  of  the  femur  be  driven  through  the 
acetabulum  into  the  pelvis,  the  injury  is  very  grave;  there 
is  then  found  shortening,  adduction,  and  semiflexion  of  the 
thigh,  absence  of  the  prominence  of  the  great  trochanter, 
and  more  capacity  for  movement  than  is  noted  in  dislocation. 
Fracture  of  the  ischium  rarely  occurs  alone. 

Treatment. — In  treating  pelvic  fractures,  endeavor  to  re- 
store the  parts  to  a  normal  position,  employing  external 
manipulation  and  inserting  a  finger  in  the  rectum  or  in  the 
vagina.  If  reduction  is  difficult,  give  ether.  Use  a  catheter 
before  dressing,  to  detect  any  bladder-injury.  Treat  as  in 
fractures  of  the  false  pelvis,  attending  carefully  to  visceral 
injuries.  If  urinary  extravasation  occurs,  effect  a  perineal 
section.  If  peritonitis  develops,  perform  a  laparotomy.  All 
visceral  injuries  are  treated  by  general  rules.  Remove  the 
dressings  in  six  weeks,  and  allow  the  patient  to  be  about 
in  twelve  weeks.  In  fracture  of  the  acetabulum,  if  the  limb 
be  shortened,  give  ether  and  reduce.  Treat  these  fractures 
in  the  same  way  as  intracapsular  fractures  of  the  femur 
(p.  372).  Fractures  of  the  ischium  are  best  treated  by 
position,  the  pad,  and  adhesive  plaster. 

Fracture  of  the  Sacrum. — This  injury  may  arise  from 
direct  force,  such  as  a  kick,  but  it  is  very  rare.  The  sacral 
plexus  is  usually  injured,  and  then  there  is  paralysis  in  the 
territory  of  its  branches. 

Symptoms. — The  symptoms  in  fracture  of  the  sacrum  are 
pain,  frequently  incontinence  of  feces  and  retention  of  urine, 
irregularity  of  the  sacral  spines,  ecchymosis,  and  crepitus. 
Crepitus  may  be  sought  for  with  one  hand  externally  and  a 


DISEASES  AXD   IXJURIES   OF  BONES  AND  JOINTS.      347 

finger  of  the  other  hand  in  the  rectum.  The  lower  fragment 
goes  forward  and  may  obstruct  or  may  tear  the  rectum. 
Paralysis  may  be  found  in  the  area  of  distribution  of  the 
sacral  plexus. 

Treatment. — In  treating  fracture  of  the  sacrum,  press  the 
fragments  into  place  with  a  hand  externally  and  a  finger  in 
the  rectum.  Do  not  plug  the  rectum.  Put  a  pad  over  the 
upper  fragment,  hold  it  with  plaster  or  a  binder,  place  the 
patient  recumbent  on  a  fracture-bed,  and  insert  a  large 
cushion  underneath  the  pad.  Give  opium  to  induce  consti- 
pation, which  allows  a  fecal  support  to  accumulate  in  the 
rectum.  Use  a  clean  catheter  regularly  and  guard  against 
bed-sores.  Union  occurs  in  about  four  weeks,  when  the 
dressing  can  be  removed.  The  patient  can  get  about  again 
in  six  weeks.  If  urinary  retention  persists  or  if  intractable 
bed-sores  form,  after  eight  or  ten  weeks  cut  down  on  the 
seat  of  injury  and  elevate  or  remove  the  portion  of  bone 
causing  pressure. 

Fractures  of  the  Coccyx. — The  coccyx  may  be  broken 
or  be  separated  from  the  sacrum  by  a  fall,  a  blow,  a  kick, 
or  the  straining  of  parturition.  Its  mobility  is  so  great, 
however,  that  it  does  not  often  break. 

Symptoms. — The  chief  symptom  of  fracture  of  the  coccyx 
is  pain,  which  is  much  aggravated  by  sitting,  walking,  or 
straining  at  stool.  If  the  index  finger  is  inserted  in  the 
rectum,  the  displaced  bone  is  felt ;  if  the  thumb  of  the  same 
hand  is  also  placed  externally,  a  rocking  motion  will  develop 
crepitus  and  preternatural  mobility. 

Treatment. — In  treating  fracture  of  the  coccyx,  reduce  by 
external  pressure  and  by  the  manipulations  of  a  finger  in 
the  rectum.  Put  the  patient  to  bed  and  obstruct  the  bowels 
by  opium  for  a  number  of  days.  In  four  weeks  the  fracture 
should  be  united.  If  union  does  not  take  place,  defecation 
and  all  movements  of  the  coccyx  will   cause  excruciating 


348  A    MANUAL    OF  SURGERY. 

pain  by  pressure  on  the  last  sacral  nerve.  This  condition, 
known  as  "  coccygodynia,"  demands  a  subcutaneous  division 
of  the  nerve  or  of  the  muscles  which  move  the  coccyx,  or 
a  resection  of  the  bone. 

Fracture  of  the  Clavicle. — The  clavicle  is  more  often 
fractured  than  any  other  bone.  This  fracture  may  occur  at 
any  age,  but  is  notably  common  before  the  sixth  year  (Hulke 
says  one-half  of  the  recorded  cases).  It  may  be  simple, 
multiple,  comminuted,  oblique,  transverse,  incomplete,  or, 
very  rarely,  compound.  Both  clavicles  may  be  broken. 
Fractures  are  most  apt  to  occur  just  external  to  the  middle, 
at  the  point  where  the  inner  or  large  curve  meets  the  outer 
or  small  curve,  at  which  junction  the  bone  is  at  its  smallest 
diameter.  Fractures  of  the  acromial  end  are  more  frequent 
than  fractures  of  the  sternal  end  and  less  frequent  than  frac- 
tures of  the  shaft.  The  causes  of  clavicle-fractures  are  direct 
violence,  indirect  violence,  and,  very  rarely,  the  contractions 
of  "  the  deltoid  and  clavicular  fibres  of  the  great  pectoral " 
(Treves,  from  Poaillon). 

Fractures  of  the  shaft  are  usually  due  to  indirect  vio- 
lence, as  falls  upon  the  shoulder  or  upon  the  hand  of  the 
outstretched  arm.  In  the  latter,  which  is  the  usual  mode 
of  origin,  the  concussion  of  the  fall  travels  up  and  the 
body-weight  travels  down,  and  these  two  forces  compress 
the  bone,  which  snaps  at  its  weakest  point.  Fractures  from 
indirect  force  are  oblique,  and  in  children  are  of  the  green- 
stick  form.  Fractures  from  direct  force  are  usually  trans- 
verse and  are  occasionally  comminuted.  Fractures  from 
muscular  action  have  been  recorded  (Rubini  the  tenor, 
recorded  by  Melay). 

Symptoms. — In  fractures  of  the  shaft  the  attitude  of  the 
patient  is  peculiar.  He  supports  the  elbow  or  wrist  of  the 
injured  side  with  the  hand  of  the  sound  side,  and  also  pulls 
the  extremity  against  the  chest;  the  head  is  turned  down 


DISEASES  AND   INJURIES    OF  BONES  AND  JOINTS.      349 

toward  the  shoulder  of  the  damaged  side,  as  if  trying  to 
Hsten  to  something  in  the  joint,  thus  relaxing  the  pull  of 
the  sterno-cleido-mastoid  muscle  upon  the  inner  fragment. 
The  shoulder  is  nearer  the  sternum,  on  a  lower  level,  and 
farther  front  than  that  of  the  sound  side.  Loss  of  func- 
tion is  shown  by  inability  to  abduct  the  arm.  Considerable 
pain  exists,  which  is  increased  by  motion,  by  pressure,  and 
by  the  extremity  hanging  down  without  support. 

The  deformity  above  noted  is  described  by  stating  that 
the  shoulder  goes  downward,  inward,  and  forward  (d.  i.  f.). 
The  doz^'Jizcard  deformity  is  chiefly  due  to  the  weight  of  the 
arm,  which  pulls  down  the  unsupported  outer  fragment,  and 
is  contributed  to  by  the  action  of  the  pectoralis  minor 
muscle.  The  inward  deformity  is  chiefly  due  to  the  con- 
traction of  the  pectoralis  minor  and  subclavius  muscles 
assisted  by  the  action  of  the  pectoralis  major.  Th.Q  forward 
deformity  is  due  to  rotation  of  the  outer  fragment,  which  is 
brought  about  b\"  the  serratus  magnus  muscle  carrying  the 
acromion  forward.  In  this  deformity  the  inner  end  of  the 
outer  fragment  is  below  and  behind  the  outer  end  of  the 
inner  fragment,  which  overrides  it.  The  inner  fragment, 
though  pulled  on  by  the  sterno-mastoid  and  relatively  higher 
than  the  outer  fragment,  is  really  but  little,  if  at  all,  elevated, 
marked  elevation  being  prevented  by  the  attachment  of  the 
rhomboid  ligament.  After  noting  the  deformity,  detect  with 
the  finger  the  irregularity  of  bony  contour.  Examine  for 
preternatural  mobility  and  crepitus  by  raising  and  throwing 
back  the  shoulder.  In  looking  for  these  signs  in  children  it 
is  to  be  remembered  that  the  fracture  is  probably  incomplete. 
The  prognosis  is  good,  the  bone  uniting,  but  always  with 
some  shortening  and  inequality. 

Complications. — Fractures  of  the  shaft  are  rarely  com- 
pound, because  the  sharp  end  of  the  outer  fragment  goes 
back  and  because  of  the  free  play  the  skin  makes  over  the 


350  A    MANUAL    OF  SURGERY. 

bone  (Pickering  Pick).  Both  clavicles  may  be  broken.  In 
fractures  from  direct  force  deeper  structures  may  be  injured 
by  fragments.  Thus,  injury  of  the  brachial  plexus  will 
induce  paralysis.  Ribs  may  be  broken  at  the  same  time. 
Trcatuioit. — In  treating  fractures  of  the  shaft,  reduce  the 
fracture  as  soon  as  possible  by  throwing  the  shoulder 
upward,  outward,  and  backward.  If  the  patient  is  a  girl, 
it  is  desirable  to  minimize  the  deformity.  Place  her  upon 
her  back  on  a  hard  bed,  with  a  small  pillow  under  her  head, 
a  firm  and  narrow  cushion  between  the  shoulders,  a  bag 
of  shot  resting  over  the  seat  of  fracture,  and  the  forearm 
lying  on  the  front  of  the  chest,  the  arm  being  held  to 
the  side  by  a  sand-bag.  In  three  weeks  there  will  be  union, 
practically  without  deformity.  In  a  child  with  an  incomplete 
fracture  a  handkerchief  sling  for  the  forearm,  worn  three 
weeks,  is  all  that  is  needed.  In  complete  fracture  the 
Velpeau  bandage  is  efficient  (PI.  13,  Fig.  4).  Before  applying 
it,  place  lint  around  the  chest  and  cotton  over  the  elbow. 
Change  the  bandage  every  day  for  the  first  week,  and  after 
that  period  every  third  day.  Each  time  it  is  changed,  rub 
the  skin  with  alcohol,  ethereal  soap,  or  soap  liniment,  then 
dry  it  and  examine  for  excoriations,  which,  if  any  are  found, 
are  anointed  with  zinc  ointment  before  the  dressing  is  reap- 
plied. The  dressing  is  permanently  removed  at  the  end  of 
four  weeks,  the  arm  being  worn  in  a  sling  for  another  week. 
The  classical  apparatus  of  Desault  is  now  rarely  used  (PL  13, 
Figs.  1-3).  The  posterior  figure-of-8  bandage  associated  with 
the  second  roller  of  Desault,  some  turns  being  made  from 
the  elbow  of  the  injured  side  to  the  shoulder  of  the  well 
side,  can  be  used  in  cases  in  which  the  forward  deformity 
is  apt  to  return.  The  apparatus  of  Fox,  which  is  very 
useful,  consists  of  a  pad  for  the  axilla,  a  sling  for  the 
forearm,  and  a  ring  for  the  opposite  shoulder,  to  which 
ring  are  tied  the  tapes  from  both  the  pad  and  the  sling. 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      35  I 


The  dressing  of  Moore  of  Rochester  is  valuable  in  an 
emergency.  The  four-tailed  bandage  is  preferred  by  Pick. 
Sayre's  dressing  has  many  advocates  (Fig.  50).  For  this 
there    are    required    two 


pieces  of  rubber  plaster, 
each  piece  being  three 
inches  wide  and  sufficiently 
long  to  go  around  the  chest 
one  and  a  half  times.  The 
end  of  one  piece  encircles 
the  arm  of  the  injured  side 
just  below  the  arm-pit ;  the 
plaster  strip  is  pulled  across 
the  back  to  the  other  side, 
to  the  front  of  the  chest, 
and 
middle  of  the  back 


returns   again   to  the 


Fig.  50. — Sayre's  Adhesive-Plaster  Dressing 
for  Fracture  of  the  Clavicle  (Stimson) :  A,  first 
piece ;    B,  second  piece. 


This  procedure  pulls  the  elbow  back 
and  throws  the  shoulder  out.  The  hand  of  the  injured 
side  is  placed  on  the  breast  of  the  opposite  side,  cotton 
being  interposed,  and  the  second  strip  of  plaster  runs  from 
the  elbow  of  the  injured  side  and  the  opposite  shoulder, 
front,  around,  and  back,  pressing  the  elbow  forward,  upward, 
and  inward. 

In  any  fracture,  if  signs  indicate  pressure  upon  vessels 
or  nerv^es,  the  patient  must  be  put  to  bed  and  the  arm  be 
abducted.  After  removing  the  dressings,  if  the  shoulder 
is  stiff,  make  passive  movements  daily ;  if  these  fail,  break 
up  the  stiffness  under  ether  or  nitrous  oxide. 

Fracture  of  the  acromial  end  of  the  clavicle  is  due  to 
direct  force.  If  the  fracture  is  between  the  two  coraco- 
clavicular  ligaments,  deformity  is  very  slight,  crepitus  is 
elicited  by  manipulating  with  the  fingers,  and  pain  exists, 
but  loss  of  function  is  not  markedly  manifest  unless  it  is 
due  to  pain.     These  fractures    are    treated  by  binding  the 


352  A   MANUAL    OF  SURGERY. 

arm  to  the  side  with  the  second  roller  of  Desault,  inter- 
posing cotton  between  the  arm  and  the  side,  and  hanging 
the  hand  in  a  sling.  In  fractures  external  to  the  liga- 
ments crepitus  is  manifest  on  moving  the  shoulder,  the  out- 
line of  the  bone  is  irregular,  severe  pain  exists  on  move- 
ment, and  deformity  is  pronounced.  The  deformity  is  due 
to  the  serratus  magnus  muscle  rotating  the  scapula  forward, 
the  inner  end  of  the  outer  fragment  of  the  clavicle  often 
coming  in  contact  with  the  anterior  surface  of  the  outer 
portion  of  the  inner  fragment.  This  fracture  is  reduced  by 
pulling  the  shoulders  back  over  the  knee,  and  it  is  kept 
reduced  by  a  posterior  figure-of-8  bandage.  In  either  frac- 
ture the  dressings  are  worn  for  four  weeks. 

Fracture  of  the  sternal  end  of  the  clavicle  is  very  rare. 
It  is  caused  by  both  direct  and  indirect  force.  There  are 
found  crepitus,  projection  at  the  seat  of  fracture,  rigidity  of 
the  sterno-mastoid  muscle,  and  shortening  of  the  clavicle. 
The  inner  end  of  the  outer  fragment  always  goes  forward, 
and  often  also  downward  and  inward.  Reduce  these  frac- 
tures by  pulling  the  shoulders  back,  and  treat  them  by 
means  of  the  posterior  figure-of-8  bandage  worn  for  four 
weeks. 

Fracture  of  the  Scapula. — This  bone  is  not  often  broken, 
as  it  rests  upon  thick  muscles  and  elastic  ribs ;  it  is  freely 
movable,  and  it  has  attached  to  it  a  bone  which  easily  breaks. 
Fractures  of  the  body  of  the  bone  are  due  to  direct  violence. 
The  symptoms  are  pain  (which  becomes  agonizing  on 
attempting  to  rotate  the  shoulder-blade),  ecchymosis,  and 
swelling.  Crepitus  is  sought  for  by  placing  the  hand  over 
the  bone  and  making  movements  of  the  arm  ;  also  by  hold- 
ing the  point  of  the  shoulder  and  lifting  up  the  lower  angle 
of  the  bone.  The  latter  plan  may  display  mobility.  The 
spine  of  the  scapula  is  uneven  only  when  it  itself  is  fractured. 
Examine  for  unevenness  of  the  vertebral  border.     In  frac- 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.       353 

tures  of  the  body  of  the  scapula  a  shoulder-cap  should  be 
applied,  a  gutta-percha  splint  must  be  moulded  over  the 
scapula,  the  arm  is  bound  to  the  side,  and  the  hand  is 
carried  in  a  sling.  The  apparatus  is  worn  for  four  weeks. 
Fractures  of  the  spine  of  the  scapula  are  treated  as  are  frac- 
tures of  the  body  of  the  bone,  and  for  the  same  time. 

Fractures  of  the  Neck. — Fracture  of  the  anatomical  neck 
has  not  been  proved  to  exist.  Fracture  of  the  surgical  neck 
is  evinced  by  flattening  of  the  shoulder,  prominence  of  the 
acromion,  and  a  lump  in  the  axilla  which  gives  crepitus  on 
pressure  upward  and  backward.  The  deformity  is  reduced 
with  ease,  but  it  at  once  recurs.  It  is  treated  by  placing  a 
pad  in  the  axilla,  a  shoulder-cap  on  the  shoulder,  applying 
the  second  roller  of  Desault,  and  supporting  the  forearm 
and  elbow  in  a  sling.  A  Velpeau  dressing  can  be  used, 
associated  with  a  folded  towel  in  the  axilla.  The  dressing 
is  to  be  worn  for  five  weeks. 

Fracture  of  the  glenoid  cavity,  which  is  not  very  unu- 
sual, may  occur  with  dislocation.  It  arises  from  direct  force 
applied  to  the  shoulder.  The  existence  of  this  fracture  is 
determined  by  excluding  fractures  of  other  bones  and  by 
detecting  crepitus  when  the  arm  is  at  right  angles  to  the 
body  and  the  humerus  is  pushed  against  the  glenoid  cavity, 
the  crepitus  not  being  found  when  the  arm  hangs  by  the 
side.  Treatment  here  is  by  the  second  roller  of  Desault  and 
a  forearm  sling  for  four  weeks  ;  then  by  careful  passive  move- 
ments limit  ankylosis,  which,  if  it  occurs,  will  have  to  be 
broken  up  under  ether  or  nitrous  oxide. 

Fracture  of  the  acromion  is  often  met  with  as  the  result 
of  direct  violence.  Its  existence  is  indicated  by  pain,  by  in- 
ability to  abduct  the  arm,  by  flattening  of  the  shoulder,  by 
sudden  lowering  of  the  point  of  the  shoulder,  by  mobility, 
and  by  crepitus.  To  treat  a  case  of  this  kind,  put  a  large 
pad  in  the  axilla  with  the  base  down,  bind  the  arm  over 

23 


354  ^    MANUAL    OF  SURGERY. 

the  pad  with  the  second  roller  of  Desault,  lifting  the  elbow 
with  turns  of  the  roller  carried  over  it  and  the  opposite 
shoulder,  thus  splinting  the  bone  in  place  by  the  head  of 
the  humerus  pushing  against  the  coraco-acromial  ligaments. 
The  dressing  is  to  be  worn  for  four  weeks. 

Fracture  of  the  coracoid,  which  rarely  happens  alone, 
may  arise  from  direct  force  or  from  muscular  action.  But 
httle  displacement  is  found.  Crepitus  and  mobility  are  usu- 
ally detected.  Inability  to  shrug  the  shoulder  inward  was 
pointed  out  as  a  symptom  by  Wellington  Byers.  These  cases 
are  well  treated  by  the  Velpeau  bandage,  which  is  to  be  worn 
for  four  weeks. 

Fractures  of  the  humerus  are  divided  into  (i)  fractures 
of  the  upper  extremity;  {2)  fractures  of  the  shaft;  and  (3) 
fractures  of  the  lower  extremity.  In  examining  any  fracture 
of  the  humerus,  feel  at  once  for  the  pulse,  so  as  to  ascertain 
if  the  artery  has  been  torn ;  in  any  fracture  near  the  head  of 
the  humerus,  be  certain  that  there  is  no  dislocation. 

I.  Fractures  of  the  upper  extremity  include  (^)  frac- 
tures of  the  anatomical  neck ;  {fi)  fractures  of  the  surgical 
neck ;  (c)  fractures  of  the  head,  oblique  and  longitudinal  ; 
and  {d^  separation  of  the  upper  epiphysis. 

Fractures  of  the  Anatomical  Neck  of  the  Humerus. — 
The  anatomical  neck  is  the  constricted  circumference  of  the 
articular  surface,  and  fractures  of  it,  though  rare,  do  occur, 
especially  in  the  aged.  The  line  of  fracture  in  some  cases 
follows  the  insertion  of  the  capsule,  in  others  it  is  entirely 
within  the  capsule,  but  in  most  it  is  without  the  capsule 
above  and  within  the  capsule  below ;  hence  the  term  "  intra- 
capsular "  is  rarely  correct  as  a  designation.  The  cause  is 
direct  violence. 

Symptovis. — The  symptoms  in  fracture  of  the  anatomical 
neck  are  pain,  swelling,  ecchymosis,  slight  irregularity  of 
the   shoulder  (which    is   soon  hidden  by  tumefaction),  and 


DISEASES  AND  INJURIES   OF  BONES  AND  JOINTS.      355 

inability  to  abduct  the  arm  voluntarily.  Deformity,  as  a 
rule,  is  slight  or  is  absent,  because  the  capsule  is  rarely 
entirely  torn  from  the  lower  fragment.  If  deformity  exists, 
it  is  due  to  the  muscles  inserted  on  the  bicipital  groove  and  to 
the  coraco-brachialis,  which  pull  the  lower  fragment  inward 
and  forward.  Treves  says  that  a  tear  of  the  reflected  fibres 
of  the  capsule  means  subsequent  necrosis,  because  this  joint 
has  no'ligamentum  teres.  In  some  cases  impaction  occurs, 
the  upper  fragment  impacting  in  the  lower.  In  this  con- 
dition there  is  very  slight  shortening  and  shoulder- flattening, 
no  crepitus  unless  the  tuberosity  is  broken  off,  and,  as  Erich- 
sen  says,  the  head  of  the  bone,  while  it  can  be  felt  through 
the  axilla,  is  not  in  the  axis  of  the  limb.  The  prognosis  of 
this  fracture  is  good  for  bony  union  (Hamilton,  Pick,  and 
R.  W.  Smith).     A  stiff  joint  is  apt  to  result. 

Treatment. — In  the  treatment  of  fracture  of  the  anatomical 
neck,  flex  the  arm  to  a  right  angle  with  the  body,  and  carry 
up  from  the  base  of  the  fingers  to  above  the  elbow  the  turns 
of  a  spiral  reverse  bandage.  Interpose  lint  between  the  arm 
and  the  side,  and  place  a  folded  towel  or  a  small  pad  in  the 
axilla,  tying  the  tapes  over  the  opposite  shoulder.  Mould 
a  shoulder-cap  (PL  7,  Fig.  8)  upon  the  outer  aspect  of  the 
arm  and  upon  the  shoulder.  This  cap,  which  is  made  of 
pasteboard  or  of  felt,  should  reach  below  the  insertion  of  the 
deltoid,  cover  one-half  the  circumference  of  the  arm,  and  is 
to  be  padded  with  cotton.  The  arm  with  the  shoulder- cap 
is  fixed  to  the  side  by  the  second  roller  of  Desault,  and  the 
hand  is  hung  in  a  sling.  The  edges  of  the  bandage  had  best 
be  stitched.  This  apparatus  is  changed  daily  for  the  first 
few  days,  the  body  and  arm  being  rubbed  at  each  change 
with  alcohol,  soap  liniment,  or  ethereal  soap.  After  this 
period  a  change  every  third  or  fourth  day  is  often  enough. 
Passive  motion  is  started  at  the  end  of  four  weeks,  and  the 
dressings  are  removed  at  the  end  of  six  weeks.     In  impacted 


356  A   MANUAL    OF  SURGERY. 

fracture  do  not  pull  apart  the  impaction,  but  apply  a  cap  to 
the  shoulder  and  fix  the  arm  to  the  side  for  five  weeks. 
No  pad  is  used.     The  fracture  unites  in  deformity. 

Fractures  of  the  Surgical  Neck  of  the  Humerus.-^The 
surgical  neck  is  the  constricted  portion  of  bone  between  the 
tuberosities  and  the  upper  line  of  the  insertion  of  the  muscles 
on  the  bicipital  groove.  Fractures  in  this  region  are  usually 
transverse,  but  they  may  be  oblique.  The  causes  are — direct 
force  almost  always;  indirect  force  occasionally;  and  mus- 
cular action  in  rare  instances. 

Symptoms. — The  symptoms  in  fracture  of  the  surgical 
neck  are — pain  running  into  the  fingers  from  pressure  upon 
the  brachial  plexus;  crepitus  and  mobility  on  extension; 
and  flattening,  which  differs  from  the  flattening  of  disloca- 
tion in  that  it  occurs  farther  below  the  acromion  and  that 
this  process  is  not  so  prominent.  Shortening  to  the  ex- 
tent of  an  inch  is  noted.  The  head  of  the  bone  can  be 
felt  in  the  glenoid  cavity,  but  it  does  not  move  on  rotating 
the  arm.  The  upper  end  of  the  lower  fragment  is  felt 
beneath  the  acromion,  and  moves  on  rotating  the  arm. 
The  displacement  is  pronounced.  The  lower  fragment  is 
pulled  upward  by  the  deltoid,  biceps,  coraco-brachialis,  and 
triceps ;  inward  by  the  muscles  of  the  bicipital  groove  ;  and 
forward  by  the  great  pectoral ;  thus,  the  upper  end  of  the 
lower  fragment  projects  into  the  axilla,  and  the  elbow  lies 
from  the  side  and  backward.  Penn  holds  that  the  violence 
sends  the  lower  fragment  forward.  The  upper  fragment  is 
abducted  and  rotated  outward,  which  is  due,  it  is  generally 
taught,  to  the  action  of  the  supraspinatus,  infraspinatus,  and 
teres  minor  muscles.  In  some  cases  displacement  is  forward, 
and  in  other  cases  it  is  not  obvious.  The  lower  fragment  may 
impact  into  the  upper,  in  which  case  the  symptoms  are 
obscure  and  the  diagnosis  is  made  by  exclusion.  If  the 
impaction  is  solid  and  complete,  there  are  the  history  of 


SPLINTS. 


Plate  8. 


I.  Bond's  Splint  in  Colles's  Fracture;  2,  Two  Straight  Splints  in  Fracture  of  both  Bones  of  the 
Forearm  ;  3,  Anterior  Angular  Splint  in  Fractures  in  or  near  the  Elbow-joint;  4,  Internal  Angu- 
lar Splint  and  Shoulder-cap  in  Fracture  of  the  Surgical  Neck  of  the  Humerus;  5,  Internal  Angu- 
lar Splint  in  Fracture  of  the  Shaft  of  the  Humerus  ;  6,  Fracture-box  in  Fractures  of  the  Bones  of 
the  Leg. 


DISEASES  AXD   INJURIES   OF  BO.\ES  AND  JOINTS.      357 

direct  force,  the  impaired  movements,  the  sh'ght  deformity, 
and  the  absence  of  crepitus.  In  all  fractures  of  the  upper 
end  of  the  humerus  the  distinction  can  be  made  from  dis- 
location by  feeling  the  head  of  the  bone  under  the  acromion 
and  by  noting  that  it  does  not  move  on  rotating  the  arm. 
The  prognosis  of  these  fractures  is  good. 

Treatment. — In  treating  a  case  of  fracture  of  the  surgical 
neck,  take  an  internal  angular  splint  (PI.  7,  Fig.  6)  and  pad  it 
well,  putting  on  extra  padding  at  the  points  that  are  to  rest 
against  the  palm,  the  inner  condyle,  and  the  axillary  folds. 
Lay  the  arm  and  pronated  forearm  upon  the  splint.  Apply  a 
padded  shoulder-cap.  Fix  the  splint  and  cap  in  place  with  a 
spiral  reverse  bandage  terminating  as  a  spica  of  the  shoulder, 
and  hang  the  hand  or  forearm  in  a  sling  (PI.  8,  Fig.  4).  The 
dressing  is  to  be  worn  for  five  weeks,  and  the  rules  to  be 
followed  in  changing  it  are  the  same  as  in  fractures  of  the 
anatomical  neck.  Motions  are  to  be  made  after  four  weeks 
to  keep  the  shoulder  from  stiffening.  Another  plan  of 
treatment  is  the  same  as  for  fracture  of  the  anatomical 
neck,  supporting  the  hand  only  in  a  sling,  so  as  to  get  the 
extending  weight  of  the  elbow,  increasing  this  weight  in 
some  cases  by  hanging  to  the  elbow  a  bag  of  shot.  In 
rare  cases — those  with  strong  anterior  projection  of  the 
upper  end  of  the  lower  fragment — apply  an  anterior  angular 
splint  (Brinton). 

Longitudinal  and  Oblique  Fracture  of  the  Head  of  the 
Humerus. — B\'  this  term  may  be  designated  separation  of 
the  great  tuberosity,  or  separation  of  a  portion  of  the  articular 
surface,  together  with  the  great  tuberosity,  from  the  shaft  and 
lesser  tuberosity  (Pickering  Pick,  Guthrie,  and  Ogston).  The 
eaitse  is  direct  violence  to  the  front  of  the  shoulder. 

Syjnptojus.—T\\Q  symptoms  in  longitudinal  and  oblique 
fiacture  of  the  head  are  broadening  and  flattening  of  the 
shoulder  with  projection  of  the  acromion.     The  upper  frag- 


358  A   MANUAL    OF  SURGERY. 

ment  passes  up  and  out,  and  the  lower  fragment  passes  up 
and  in  to  rest  on  the  margin  of  the  glenoid  cavity  below 
the  coracoid.  The  elbow  is  drawn  from  the  side,  there  is 
some  shortening,  and  the  patient  cannot  abduct  his  arm.  If 
the  elbow  be  grasped  and  held  to  the  side  and  the  arm  be 
rotated  while  the  other  hand  grasps  the  upper  fragment, 
crepitus  is  very  positive.  Examination  develops  wide  sepa- 
ration of  the  fragments.  The  deformity  cannot  be  entirely 
corrected,  because  the  biceps  tendon  gets  between  the 
fragments  (Ogston),  but  a  useful  limb  can  usually  be 
obtained. 

TrcaUnciit. — The  plan  which  gives  the  best  result  in  treat- 
ing longitudinal  and  oblique  fracture  of  the  head  is  to  place 
the  patient  on  his  back  upon  a  hard  bed  with  a  small  firm 
pillow  under  his  head,  and  to  abduct  the  arm  above  the 
head,  rotate  it  outward  so  that  the  back  of  the  hand  rests 
on  the  bed,  and  hold  it  in  place  by  sand-bags.  This  position 
should  be  maintained  for  three  weeks,  at  the  end  of  which 
period  the  fracture  can  be  dressed  for  three  weeks  more  as  a 
fracture  of  the  anatomical  neck.  If  the  patient  refuses  to  go 
to  bed,  treat  the  injury  as  a  fracture  of  the  anatomical  neck, 
padding  well  over  the  tuberosities.  The  dressings  should  be 
worn  for  six  weeks,  passive  motion  being  made  after  four 
weeks.  In  all  the  above  injuries — in  fact,  in  all  fractures  of 
the  humerus — feel  at  once  for  the  pulse,  to  see  if  the  artery 
has  been  torn. 

Separation  of  the  Upper  Epiphysis. — The  epiphysis  is 
united  during  the  twentieth  year,  its  separation  being  a  rare 
accident  and  being  produced  by  direct  force. 

Symptoms. — The  chief  symptom  in  separation  of  the  upper 
epiphysis  is  projection  of  the  upper  end  of  the  lower  frag- 
ment inward,  forward,  and  upward  beneath  the  coracoid,  and 
consequently  a  projection  of  the  elbow  backward  and  from 
the  side.     If  only  the  lower  fragment  passes  forward,  the 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      359 

elbow  simply  passes  back.  The  upper  end  of  the  lower  frag- 
ment is  smooth  and  convex.  Rotation  of  the  shaft  develops 
soft  crepitus. 

The  prognosis  is  good  for  bony  union,  though  the  future 
growth  of  the  limb  may  be  impaired. 

Trcatmoit. — The  treatment  for  separation  of  the  upper 
epiphysis  is  a  pad  in  the  axilla,  a  shoulder-cap,  binding 
the   arm  to  the  side,  and  hanging  the  hand  in  a  sling. 

2.  Fracture  of  the  Shaft  of  the  Humerus. — Fracture 
of  the  shaft  of  the  humerus  is  a  very  common  accident. 
The  cause  is  usually  direct  violence,  such  as  a  blow.  The 
fracture  may  arise  from  indirect  violence,  such  as  a  fall  upon 
the  elbow.  Muscular  action  is  not  rarely  also  a  cause,  as 
in  throwing  a  ball,  in  catching  a  tree-limb  while  falling,  or 
in  turning  another's  wrist  as  a  test  of  strength  (Treves). 

Symptoms. — The  symptoms  of  a  fractured  shaft  are  pain, 
swelling,  ecchymosis,  inability  to  move  the  arm,  mobility,  and 
distinct  crepitus.  Shortening  to  the  extent  of  three-fourths  of 
an  inch  occurs.  The  displacement  varies  with  the  situation  of 
the  fracture  and  the  direction  of  the  force.  If  the  fracture 
is  above  the  insertion  of  the  deltoid,  the  lower  fragment  is 
pulled  up  by  the  triceps,  biceps,  and  deltoid,  and  pulled  out  by 
the  deltoid,  and  the  upper  fragment  is  pulled  inward  by  the 
arm-pit  muscles.  In  fracture  below  the  deltoid  this  muscle 
is  apt  to  pull  the  lower  end  of  the  upper  fragment  outward, 
while  the  lower  fragment  passes  inward  and  upward  because 
of  the  action  of  the  biceps  and  triceps. 

The  prognosis  is  good,  but  the  fact  should  always  be 
remembered  that  ununited  fractures  are  commoner  in  the 
humerus  than  in  any  other  bone.  Treves  believes  this  to 
be  due  to  entanglement  of  muscle  between  the  fragments, 
lack  of  fixation  of  the  shoulder-joint,  and  imperfect  elbow- 
support.  PTamilton  believes  that  it  is  due  to  the  facts  that 
the  elbow  soon  becomes  fixed  at  a  right  angle,  and  that  any 


360  A   MANUAL    OF  SURGERY. 

movement  of  the  forearm  moves  the  seat  of  fracture,  and 
not  the  elbow. 

Treatment. — The  treatment  for  fracture  of  the  humerus 
is  an  internal  angular  splint  without  the  shoulder-cap.  If 
deformity  is  not  corrected,  associate  with  this  splint  three 
short  humeral  splints  instead  of  the  shoulder-cap  used  in 
fractures  near  the  shoulder-joint.  Splints  arc  to  be  worn 
for  six  weeks.  Passive  movements  are  not  to  be  made  until 
the  fracture  is  well  united  (after  six  weeks),  for,  if  made  too 
soon,  they  predispose  to  non-union,  and,  as  no  joint  is  in- 
volved, ankylosis  will  not  occur  (PI.  8,  Fig.  5). 

3.  Fractures  of  the  Lower  Extremity  of  the  Humerus. 
— These  fractures  are  spoken  of  as  fractures  in,  or  in  the 
neighborhood  of,  the  elbow-joint,  and  they  include  {ci)  frac- 
ture of  the  external  condyle ;  [b]  fracture  of  the  internal 
condyle;  {c)  fracture  of  the  internal  epicondyle;  (d)  frac- 
ture at  the  base  of  the  condyles ;  {e)  T-fracture ;  and  (/) 
epiphyseal  separation.  In  all  injuries  of  the  elbow-joint, 
give  ether  in  making  the  diagnosis  (Brinton). 

Fracture  of  the  External  Condyle  of  the  Humerus. — 
A  fracture  of  the  external  condyle  runs  into  the  joint  and 
the  capitellum  is  usually  broken  off.  This  injury  occurs 
oftenest  in  children  by  falling  on  the  hand,  but  it  may  occur 
from  direct  force,  and  may  happen  to  adults. 

Symptoms. — The  symptoms  of  fracture  of  the  external 
condyle  are  pain,  great  swelling,  impaired  function,  and 
crepitus  (found  on  pressing  or  moving  the  condyle).  Mobil- 
ity may  also  be  discovered. 

Fracture  of  the  Inner  Epicondyle  of  the  Humerus. — 
The  inner  epicondyle  is  an  epiphysis  which  unites  during 
the  seventeenth  year.  It  not  infrequently  breaks  from  mus- 
cular action  or  from  direct  violence,  the  fracture  not  in- 
volving the  joint.  Displacement  is  slight.  The  ante}"  epi- 
condyle does  not  break. 


DISEASES  AXD   IXJURIES   OF  BONES  AND  JOINTS.      36 1 

Fracture  of  the  Internal  Condyle  of  the  Humerus. — 
The  line  of  fracture  of  the  internal  condyle  runs  into  the 
joint,  to  the  trochlear  surface  of  the  humerus.  The  cause 
is  always  direct  violence. 

Symptoms. — In  fracture  of  the  internal  condyle  the  frag- 
ment, accompanied  by  the  ulna,  goes  upward  and  backward, 
and  when  the  forearm  is  extended  the  ulna  projects  posteri- 
orly, the  lower  end  of  the  humerus  being  felt  in  front. 
Crepitus  and  preternatural  mobility  can  be  found  if  swelling 
is  not  too  great.  The  space  between  the  condyles  is  broader 
than  normal  and  the  forearm  takes  a  bend  toward  the  ulnar 
side,  the  carrying  function  of  the  forearm  being  lost  (Brin- 
ton) ;  that  is,  if  a  bucket  be  held  in  the  hand,  it  would  strike 
the  leg. 

Fracture  at  the  Base  of  the  Condyles  of  the  Humerus. 
— This  fracture  is  just  above  the  olecranon  and  is  on  a 
higher  level  behind  than  in  front.  The  cause  is  direct  force 
upon  the  olecranon. 

The  symptoms  are  loss  of  function  and  pain  from  injury 
of  the  median  or  ulnar  nerves.  Crepitus  and  mobility  are 
readily  found.  The  lower  fragment  goes  backward  and 
upward  by  the  action  of  the  triceps,  biceps,  and  brachialis 
anticus.  The  lower  end  of  the  upper  fragment  projects  in 
front  of  the  joint. 

T-fracture  of  the  Humerus. — This  fracture  is  a  trans- 
verse fracture  above  the  condyles  plus  a  vertical  fracture 
between  them.  The  cause  is  violent  direct  force  applied 
posteriorly. 

Symptoms. — The  symptoms  are  increase  in  breadth  of  the 
joint,  preternatural  mobiHty,  crepitus,  pain,  and  swelling. 

Fractures  In  or  Near  the  Elbow-jomt. — Prognosis  and 
Treatment. — The  prognosis  for  complete  restoration  of  func- 
tion is  bad,  and  in  most  of  these  fractures  some  deformity 
and  considerable  stiffness  are  inevitable.     Callus  poured  into 


362  A    MANUAL    OF  SURGERY. 

a  joint  acts  like  a  stone  pushed  into  the  crack  of  a  door: 
it  Hmits  or  prevents  motion.  Give  ether  for  diagnosis  and 
the  first  dressing.  If  swelling  is  so  great  that  the  surgeon 
dare  not  apply  a  splint,  let  him  rest  the  arm,  semiflexed, 
upon  a  pillow  and  apply  lead-water  and  laudanum  for  a 
day  or  two.  The  position  for  splinting  is  to  be  full  supina- 
tion, which  is  obtained  by  so  placing  the  hand  of  the  patient 
that  he  could  easily  spit  into  the  palm  (Brinton).  Apply  a 
well-padded  anterior  angular  splint  (a  right-angled  splint ;  PI. 
7,  Fig.  5  ;  PL  8,  Fig.  3).-  If  posterior  projection  exists,  mould 
a  pasteboard  cup  over  the  elbow  or  apply  a  trough.  In 
applying  the  anterior  angular  splint,  first  fasten  the  upper 
end  to  the  arm,  then  make  extension  of  the  elbow,  and 
fasten  the  lower  end  of  the  splint  to  the  extended  forearm. 
This  splint  is  to  be  worn  for  four  or  five  weeks,  removing  it 
carefully  every  third  day.  Begin  passive  motion  at  the 
end  of  the  second  week.  After  the  dressings  are  removed 
employ  passive  motion,  massage,  hot  and  cold  douches,  in- 
unctions of  ichthyol  or  mercurial  ointment,  iodine  locally, 
corrosive  sublimate  and  iodide  of  potassium  internally,  and 
direct  the  patient  to  systematically  use  the  arm.  Many 
surgeons  at  the  end  of  the  second  week  apply  a  Stromeyer 
splint  which  permits  the  patient  and  the  surgeon  to  make 
some  motion  by  means  of  the  screw  (Fig.  67).  In  children 
or  in  very  stout  people  an  anterior  angular  splint  will  not 
stay  in  place,  in  which  case  the  arm  should  be  put  at  a  right 
angle  and  plaster  of  Paris  be  used.  If,  on  removing  an 
angular  splint  from  any  case  after  four  weeks,  non-union 
exists,  put  up  the  arm  in  an  immovable  splint  for  three  or 
four  weeks  more. 

Epiphyseal  separation  of  the  humerus  is  a  not  unusual 
accident.  The  inferior  extremity  of  the  humerus  may  be 
separated,  or  the  condyles  may  be  separated  from  each  other 
and  from  the  shaft  of  the  bone. 


DISEASES  AXD   IXJURIES   OF  BONES  AAD  JOINTS.      363 

Symptoms. — The  symptoms  are — prominence  in  front  of 
the  joint,  caused  by  the  lower  end  of  the  shaft  of  the 
humerus;  projection  backward  of  the  olecranon;  hand  mid- 
way between  pronation  and  supination.  Epiphyseal  separa- 
tion may  retard  growth  and  produce  deformity. 

Fractures  of  the  ulna  comprise  the  following  varieties  : 
(i)  fracture  of  the  coronoid  process;  (2)  fracture  of  the  olec- 
ranon process  ;  (3)  fracture  of  the  shaft;  and  (4)  fracture  of 
the  styloid  process. 

Fracture  of  the  coronoid  process  of  the  ulna  occurs  only 
as  a  complication  of  a  backward  dislocation  or  in  associa- 
tion with  other  fractures. 

Symptoms. — When  fracture  of  the  coronoid  process  is 
associated  with  a  dislocation  there  is  produced  crepitus  on 
reduction,  and  it  is  found  that  the  deformity  of  the  disloca- 
tion promptly  returns  on  cessation  of  extension.  The  upper 
fragment  may  be  pulled  up  by  the  brachialis  anticus,  and 
there  exists  an  inability  to  flex  the  forearm  completely.  The 
position  is  one  of  extension  with  posterior  projection  of  the 
olecranon.     The  broken  piece  is  felt  in  front  of  the  joint. 

Treatment. — The  treatment  is  by  an  anterior  splint  whose 
angle  is  less  than  a  right  angle ;  the  splint  is  to  be  worn 
for  four  weeks,  and  passive  motion  is  to  be  begun  in  the 
third  week.     A  stiff  joint  is  probable. 

Fracture  of  the  olecranon  process  of  the  ulna  is  not  an 
uncommon  injury  in  adults.  Hulke  states  that  it  never  occurs 
before  the  age  of  fifteen,  but  the  writer  has  seen  in  the  Jeffer- 
son Hospital  a  girl  aged  fourteen  with  a  fractured  olecranon. 
The  cause  is  direct  violence  or  muscular  action.  Only  a 
small  fragment  may  be  torn  away  or  the  greater  part  of  the 
olecranon  m.ay  be  broken  off,  and  the  break  may  be  com- 
minuted or  even  be  compound. 

Symptoms. — The  symptoms  of  fracture  of  the  olecranon 
are — swelling ;  partial  flexion  of  forearm  ;  separation  of  frag- 


364  A   MANUAL    OF  SURGERY. 

ments,  the  upper  piece  being  pulled  up  from  half  an  inch 
to  two  inches  by  the  triceps ;  the  space  between  the  frag- 
ments is  increased  by  forearm  flexion  and  lessened  by  fore- 
arm extension  ;  there  is  inability  to  extend  the  arm.  Bulging 
of  the  triceps  above  the  fragments  and  crepitus  on  approxi- 
mating the  fragments  are  observed.  The  prognosis  is  fair, 
fibrous  union  being  the  rule.  Some  joint-stiffness  usually 
occurs,  and  much  ankylosis  may  be  unavoidable. 

Treatment. — The  treatment  calls  for  a  well-padded  anterior 
splint,  almost  but  not  quite  straight.  A  perfectly  straight 
splint  is  uncomfortable,  and,  by  opening  a  retiring  angle 
between  the  fragments  and  into  the  joint,  favors  non-union 
and  ankylosis.  The  splint  should  reach  from  a  level  with 
the  axillary  margin  to  below  the  fingers.  If  the  upper  frag- 
ment does  not  come  in  contact  with  the  lower,  pull  it  down 
by  adhesive  plaster  and  fasten  the  strips  to  the  splint.  The 
author  in  one  case  employed  a  glove  to  which  strings  from 
the  adhesive  plaster  were  attached.  The  danger  of  anky- 
losis in  this  fracture  is  very  great,  and,  in  case  it  occurs 
in  the  position  of  extension,  means  an  almost  useless  arm. 
Pickering  Pick  at  the  end  of  three  weeks  anaesthetizes  the 
patient,  presses  his  thumb  firmly  down  upon  the  top  of  the 
olecranon,  puts  the  forearm  at  a  right  angle,  and  applies  an 
anterior  angular  splint  and  directs  it  to  be  worn  for  two 
weeks,  passive  motion  being  made  every  other  day.  When 
the  splint  is  removed,  try  to  obtain  motion  as  previously 
directed.     Non-union  requires  wiring  of  the  fragments. 

Fracture  of  the  shaft  of  the  ulna  is  most  apt  to  be  near 
the  middle,  is  always  due  to  direct  violence,  and  is  not  un- 
usually compound.     The  radius  may  also  be  broken. 

Symptoms. — By  running  the  finger  along  the  inner  sur- 
face of  the  bone  there  are  detected  inequality  and  depression  ; 
crepitus  and  mobility  are  developed  ;  there  are  pain  and  the 
evidences  of  direct  violence.     The  long  axis  of  the  hand  is 


DISEASES  AND   INJUKIES   OF  BONES  AND  JOINTS.      365 

not  in  a  line  with  the  long  axis  of  the  forearm,  but  is  internal 
to  it.  If  deformity  exists,  it  is  due  to  the  lower  fragment 
passing  into  the  interosseous  space  because  of  the  action  of 
the  pronator  quadratus  muscle ;  the  upper  fragment,  acted 
on  by  the  brachialis  anticus,  passes  a  little  forward.  The 
forearm  at  and  below  the  seat  of  fracture  is  narrower  and 
thicker  than  normal. 

Tr-catniciit. — In  treating  fracture  of  the  shaft,  place  the 
forearm  midway  between  pronation  and  supination,  so  as  to 
bring  the  fragments  together  and  to  obtain  the  widest  pos- 
sible interrosseous  space ;  this  limits  the  danger  of  ankylosis 
in  this  space.  The  position  midway  between  pronation  and 
supination  is  marked  by  flexing  the  forearm  to  a  right  angle 
with  the  arm  and  pointing  the  thumb  to  the  nose.  Take 
two  well-padded  straight  splints,  one  long  enough  to  reach 
from  the  inner  condyle  to  below  the  fingers,  the  other  from 
the  outer  condyle  to  below  the  wrist ;  place  a  long  pad 
over  the  interosseous  space  on  the  flexor  side  of  the  limb, 
and  another  on  the  extensor  side  ;  apply  the  splints  and  hang 
the  arm  in  a  triangular  sling  (PI.  8,  Fig.  2).  Passive  motion 
is  to  be  made  in  the  third  week,  and  the  splints  are  to  be 
worn  for  four  weeks. 

Fracture  of  the  styloid  process  of  the  ulna  is  due  to 
direct  force.     The  displacement  is  obvious. 

Treatment. — In  treating  fracture  of  the  styloid  process, 
push  the  fragment  back  into  place  and  use  a  Bond  splint 
with  a  compress  for  four  weeks. 

Fractures  of  the  radius  include  the  following  varieties : 
{a)  fractures  of  its  head  ;  {li)  fractures  of  its  neck ;  {c)  frac- 
tures of  its  shaft;  and  {d^  fractures  of  its  lower  extremity. 

Fracture  of  the  head  of  the  radius  very  rarely  occurs 
alone,  but  it  may  complicate  backward  dislocation  of  the 
radius  and  the  ulna. 

Symptoms. — The  symptoms  of  fracture  of  the  head  of  the 


366  A   MANUAL    OF  SURGERY. 

radius  are  crepitus  on  making  pronation  and  supination,  and 
loss  of  voluntary  pronation  and  supination. 

Treatment. — The  treatment  of  fracture  of  the  head  of  the 
radius  is  the  same  as  for  a  fracture  in  or  near  the  elbow- 
joint — namely,  an  anterior  angular  splint  for  four  or  five 
weeks,  with  passive  motion  in  the  third  week  (PL  8,  Fig.  3). 

Fracture  of  the  neck  of  the  radius  rarely  occurs  alone. 

Symptoms.  —  In  this  fracture  the  forearm  is  pronated  and 
the  patient  is  found  to  have  lost  the  power  of  voluntary  pro- 
nation and  supination.  Under  forced  pronation  and  supina- 
tion it  will  be  noted  that  the  head  of  the  radius  does  not 
move  and  crepitus  is  felt.  The  lower  fragment,  being 
pulled  up  and  forward  by  the  biceps,  can  be  felt  in  front 
of  the  elbow-joint. 

Treatment. — The  treatment  for  fracture  of  the  neck  of  the 
radius  is  the  same  as  for  fracture  of  the  elbow-joint — namely, 
an  anterior  angular  splint  for  four  or  five  weeks  (PI.  8,  Fig.  3). 

Fracture  of  the  shaft  of  the  radius  is  far  commoner 
than  fracture  of  the  shaft  of  the  ulna.  It  may  occur  above 
or  below  the  insertion  of  the  pronator  radii  teres  muscle.  It 
may  arise  from  either  direct  or  indirect  force. 

Fracture  of  the  Radius  above  the  Insertion  of  the 
Pronator  Radii  Teres  Muscle. — Symptoms. — The  upper 
fragment  is  drawn  forward  by  the  biceps  and  is  fully  supi- 
nated  by  the  supinator  brevis.  The  lower  fragment  is  fully 
pronated  by  the  pronator  quadratus  and  pronator  radii  teres, 
and  its  upper  end  is  pulled  into  the  interosseous  space. 
There  are  crepitus,  mobility,  pain,  narrowing  and  thickening 
of  the  forearm  below  the  seat  of  fracture,  and  loss  of  the 
power  of  pronation  and  supination.  The  head  of  the  bone 
is  motionless  during  these  movements,  and  the  hand  is  prone. 

Treatment. — In  treating  this  fracture,  do  not  put  the 
forearm  midway  between  pronation  and  supination,  as  this 
position  will  not  bring  the  fragments  into  contact,  the  upper 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.       367 

fragment  remaining  flexed  and  supinated.  To  bring  the 
lower  fragment  in  contact  with  the  upper,  flex  and  fully 
supinate  the  forearm.  Put  the  arm  upon  an  anterior  angular 
splint  for  four  weeks  (PI.  8,  Fig.  3),  and  make  passive  motion 
in  the  third  week. 

Fracture  of  the  Radius  below  the  Insertion  of  the 
Pronator  Radii  Teres  Muscle. — In  this  variety  of  fracture 
the  upper  fragment  is  acted  on  by  the  biceps,  the  supinator 
brevis,  and  the  pronator  radii  teres,  and  it  remains  about 
midway  between  pronation  and  supination,  passing  forward 
and  also  into  the  interosseous  space.  The  lower  fragment 
is  acted  on  by  the  supinator  longus  and  the  pronator  quad- 
ratus,  the  latter  being  the  more  powerful  of  the  two,  and  the 
lower  fragment  is  moderately  pronated,  its  upper  extremity 
being  thrown  into  the  interosseous  space.  Other  symptoms 
are  identical  with  those  of  fracture  above  the  insertion  of  the 
pronator  radii  teres. 

TrcatiJicnt. — In  treating  fracture  below  the  pronator  radii 
teres,  the  forearm  is  flexed  and  is  placed  midway  between 
pronation  and  supination ;  interosseous  pads  and  two  straight 
splints  are  applied  as  for  fracture  of  the  ulna  (PL  8,  Fig.  2). 
The  splints  are  worn  for  four  weeks,  and  passive  motion  is 
made  in  the  third  week. 

Fracture  of  the  shafts  of  both  bones  of  the  forearm  is 
not  frequently  seen.     It  is  caused  by  direct  or  indirect  force. 

Symptoms. — In  fractures  of  both  bones  of  the  forearm  the 
hand  is  pronated  and  the  two  lower  fragments  come  together 
and  are  drawn  upward  and  backward  or  upward  and  forward 
by  the  combined  force  of  flexor  and  extensor  muscles,  short- 
ening being  manifest  and  a  projection  being  detected  on 
either  the  dorsal  or  the  flexor  surface  of  the  forearm.  The 
upper  fragment  of  the  ulna  is  somewhat  flexed  by  the 
brachialis  anticus  ;  the  upper  fragment  of  the  radius  is  flexed 
by  the  biceps  and  is  pronated  and  drawn  toward  the  ulna  by 


368  A   MANUAL    OF  SURGERY. 

the  pronator  radii  teres.  The  forearm  is  narrower  than  it 
should  be  (the  ends  of  the  fragments  having  passed  into  the 
interosseous  space)  and  is  thicker  than  normal  (the  contents 
of  the  interosseous  space  having  been  forced  out).  Crepitus, 
mobility,  pain,  and  inequality  exist,  the  power  of  rotation  is 
lost,  and  on  passive  rotation  the  head  of  the  radius  does  not 
move.     The  forearm  is  prone  and  semiflexed. 

Treatment. — The  treatment  requires  two  straight  splints 
and  two  interosseous  pads,  the  forearm  flexed  to  a  right 
angle  and  placed  midway  between  pronation  and  supination 
(PL  8,  Fig.  2).  The  splints  are  worn  for  four  weeks,  and 
passive  motion  is   made   in  the  third  week. 

Fracture  of  the  Lower  Extremity  of  the  Radius. — Bar- 
ton's fracture  is  oblique  and  runs  into  the  joint.  Colics  s 
fracture  is  a  transverse  or  moderately  oblique  fracture  of  the 
lower  end  of  the  radius,  between  the  limits  of  one-quarter 
of  an  inch  and  one  and  a  half  inches  above  the  wrist-joint, 
the  lower  fragment  mounting  upon  the  dorsum  of  the  upper 
piece.  Colics' s  fracture,  a  very  common  injury,  is  met  with 
more  frequently  in  those  beyond  the  age  of  forty,  and  oftener 
in  women  than  in  men.  It  is  due  to  transmitted  force  (a  fall 
upon  the  palm  of  the  pronated  hand),  the  force  being  received 
by  the  ball  of  the  thumb  and  passing  to  the  carpal  bones  and 
the  edge  of  the  radius  ;  a  fracture  begins  posteriorly  rather 
than  anteriorly,  the  force  driving  the  fragment  upon  the 
dorsal  surface  of  the  radius.  Some  hold  that  this  fracture 
is  due  to  sudden  traction  upon  the  anterior  ligaments,  which 
drag  upon  the  bone  and  break  it  at  the  point  where  the 
cancellous  end  of  the  radius  joins  the  compact  shaft. 

Symptoms. — In  CoUes's  fracture  the  hand  is  abducted 
(drawn  to  the  radial  side  of  the  forearm)  and  pronated, 
the  head  of  the  ulna  is  prominent,  the  styloid  process  of 
the  radius  is  raised,  and  the  lower  fragment,  which  mounts 
on  the  back  of  the  lower  end  of  the  upper  fragment,  causes 


DISEASES  AND   ENJURIES   OF  BONES  AND  JOINTS.      369 

a  dorsal  projection  termed  by  Liston  the  "  silver-fork  de- 
formity." The  lower  end  of  the  upper  fragment  can  be  felt 
beneath  the  flexor  tendons  above  the  wrist.  The  position 
in  deformity  is  produced  by  the  force  and  is  maintained  by 
the  action  of  the  supinator  longus  and  the  flexor  and  exten- 
sor muscles,  but  particularly  by  the  extensors  of  the  thumb. 
Pronation  and  supination  are  lost.  Crepitus,  which  is  best 
obtained  by  alternate  hyperextension  and  flexion,  can  be 
secured  unless  swelling  is  great  or  impaction  exists.  Crepi- 
tus on  side  movements  is  rarely  obtainable.  Impaction  may 
greatly  modify  the  deformity,  though  displacement  generally 
exists  to  some  extent,  and  the  fragments  do  not  ride  easily 
on  each  other.  The  styloid  process  of  the  ulna  may  be 
broken,  or  the  inferior  radio-ulnar  articulation  may  be  sepa- 
rated. This  latter  complication  allows  the  lower  fragment 
to  roll  freely  upon  the  upper,  and  the  characteristic  silver- 
fork  deformity  does  not  appear.  If  the  styloid  process  of  the 
ulna  is  broken,  pressure  over  it  causes  great  pain.  If  a  person 
in  falling  strikes  the  back  of  the  hand  and  a  fracture  of  the 
radius  occurs,  the  lower  fragment  is  driven  upon  the  front 
surface  of  the  upper  fragment  and  is  felt  under  the  flexor 
tendons  at  the  wrist. 

Treatment. — In  treating  Colles's  fracture,  reduce  the  de- 
formity by  hyperextension  to  unlock  the  fragments,  by  lon- 
gitudinal traction,  and  by  forced  flexion.  The  extremity  can 
be  placed  upon  a  Levis  splint,  the  position  maintaining  reduc- 
tion and  the  tense  extensor  tendons  giving  dorsal  support.  The 
favorite  splint  in  Philadelphia  practice  is  Bond's.  It  places 
the  hand  in  a  natural  position  of  rest  (semiflexion  of  the  fingers, 
semi-extension  of  the  wrist,  and  deviation  of  the  hand  toward 
the  ulna).  Two  pads  are  used  :  a  dorsal  pad  which  overlies 
the  lower  fragment,  and  a  pad  for  the  flexor  surface  which 
overlies  the  upper  fragment.  A  bandage  is  applied,  the 
thumb  and  fingers  being  left  free  (PI.  8,  Fig.  i  ;  PL  7,  Fig.  7). 

24 


370  A   MANUAL    OF  SURGERY. 

Passive  motion  is  begun  upon  the  fingers  in  three  or  four  days, 
and  upon  the  wrist  during  the  second  week.  The  sphnt  is 
removed  in  three  weeks,  and  a  bandage  is  worn  for  a  week 
or  two  more  because  of  the  swelling.  In  applying  the  Bond 
splint,  do  not  pull  the  hand  too  much  up  on  the  block,  or 
the  fracture  will  unite  with  a  projection  upon  the  flexor 
surface  of  the  extremity  and  the  tendons  of  the  wrist  will 
be  apt  to  be  caught  in  the  callus.  If  a  stiff  joint  and 
limited  tendon-motion  eventuate  from  the  fracture,  use 
massage,  frictions,  sorbefacient  ointments,  tincture  of  iodine, 
electricity,  and  hot  and  cold  douches,  or  give  ether  and 
forcibly  break  up  adhesions.  Some  surgeons  dress  Colles's 
fracture  with  a  band  of  adhesive  plaster  around  the  wrist 
and  support  the  extremity  in  a  sling  (Pilcher). 

Fracture  of  both  the  Radius  and  Ulna  near  the  "Wrist. 
— Colles's  fracture  may  be  complicated  by  a  fracture  of  the 
ulna  other  than  of  its  styloid  process. 

Symptoms. — In  fracture  of  the  radius  and  ulna  near  the 
wrist  the  lower  ends  of  the  upper  fragments  come  together, 
the  upper  fragment  of  the  radius  is  pronated,  and  the  lower 
fragment  of  the  radius  is  drawn  up.  Pain,  crepitus,  mobility, 
shortening,  and  loss  of  function  exist. 

Treatment. — A  fracture  of  the  radius  and  ulna  requires  the 
use  of  the  Bond  splint,  as  for  Colles's  fracture. 

Separation  of  the  Lower  Radial  Epiphysis. — This  acci- 
dent occurs  in  children  from  falling  upon  the  palm  of  the 
hand.     It  never  happens  after  the  twentieth  year. 

Symptoms. — In  separation  of  the  lower  radial  epiphysis 
the  lower  fragment  mounts  upon  the  upper  and  produces  a 
dorsal  projection  like  Colles's  fracture,  but  the  hand  does  not 
deviate  to  the  radial  side.  The  deformity  resembles  that  of 
a  backward  carpal  dislocation,  but  is  differentiated  from  dis- 
location by  the  unaltered  relation  in  the  fracture  between  the 
styloid  processes  and  the  carpal  bones. 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      37 1 

Treatment. — The  treatment  in  separation  of  the  lower 
radial  epiphysis  consists  of  the  use  of  a  Bond  splint,  as  in 
Colles's  fracture. 

Fractures  of  the  carpus  are  not  frequent,  and  they  are 
usually  compound.     The  eause  is  violent  direct  force. 

Symptoms. — Fractures  of  the  carpus  are  indicated  by  pain, 
swelling,  evidences  of  direct  force,  sometimes  crepitus,  loss 
of  power  in  the  hand,  and  a  very  little  displacement. 

Treatment. — Many  compound  comminuted  fractures  of 
the  carpus  require  amputation.  In  an  ordinary  com- 
pound fracture,  asepticize,  drain,  dress  with  antiseptic  gauze 
and  a  plaster-of-Paris  bandage,  cutting  trap-doors  in  the 
plaster  over  the  ends  of  the  drainage-tube.  In  a  simple 
fracture,  use  lead-water  and  laudanum  for  a  few  days. 
Dress  the  hand  upon  a  well-padded  straight  palmar  splint 
(PI.  7,  Fig.  10)  reaching  from  beyond  the  fingers  to  the  mid- 
dle of  the  forearm,  and  place  the  hand  and  forearm  in  a  sling. 
The  splint  is  worn  for  four  weeks,  and  passive  motion  of  the 
wrist  is  begun  in  the  second  week. 

Fracture  of  the  Metacarpal  Bones. — Metacarpal  frac- 
ture is  v^ery  common.  One  or  more  bones  may  be  broken. 
The  first  metacarpal  bone  is  oftenest  broken  ;  the  third  is 
rarely  broken  (Hulke).    The  eause  is  direct  or  indirect  force. 

Symptoms. — The  signs  of  a  metacarpal  fracture  are — 
dorsal  projection  of  the  upper  end  of  the  lower  fragment, 
the  head  of  the  bone  being  felt  in  the  palm  ;  pain  ;  crepitus  ; 
and  often  evidences  of  direct  violence. 

Treatmefit. — To  treat  a  fracture  of  the  metacarpal  bones, 
reduce  by  extension  ;  place  a  large  ball  of  oakum,  cotton, 
or  lint  in  the  palm  to  maintain  the  natural  rotundity,  and 
apply  a  straight  palmar  splint  like  that  used  in  fractures  of  the 
carpus  (PI.  7^  Fig.  10).  It  may  be  necessary  to  apply  a  com- 
press over  the  dorsal  projection.  The  duration  of  treatment 
is  three  weeks,  and  passive  motion  is  begun  after  two  weeks. 


372  A   MANUAL    OF  SURGERY. 

Fractures  of  the  Phalanges. — The  phalanges  are  often 
broken.  The  fracture  may  be  compound.  The  cause  usually 
is  direct  force. 

Symptoms. — Fracture  of  the  phalanges  is  indicated  by 
pain,  bruising,  crepitus,  and  mobility,  with  very  little  or 
no  displacement. 

Treatment. — If  the  middle  or  distal  phalanx  is  broken, 
mould  on  a  trough-like  splint  of  gutta-percha  or  of  paste- 
board, which  splint  need  not  run  into  the  palm.  If  the 
proximal  phalanx  is  broken,  run  the  splint  into  the  palm  of 
the  hand.  Make  the  splint  of  gutta-percha,  pasteboard,  wood, 
or  leather.  The  splint  is  worn  three  weeks.  A  sling  must  be 
worn,  otherwise  the  finger  will  constantly  be  knocked  and  hurt. 
Some  cases  require  a  dorsal  as  well  as  a  palmar  splint. 

Fracture  of  the  femur  is  a  very  common  injury.  The 
divisions  of  the  femur  are  (i)  the  upper  extremity;  (2)  the 
shaft ;  and  (3)  the  lower  extremity. 

I.  Fractures  of  the  upper  extremity  of  the  femur  are 
divided  into  {a)  intracapsular;  {6)  extracapsular;  (r)  of  the 
great  trochanter;  and  id)  epiphyseal  separation  (either  of 
great  trochanter  or  head). 

Intracapsular  Fracture  of  the  Femur. — This  fracture 
of  the  neck  is  transverse  or  only  slightly  oblique,  and  is  not 
unusually  impacted.  The  cause  is  slight  indirect  force,  of 
the  nature  of  a  twist,  acting  upon  a  person  of  advanced  years 
(more  often  a  woman  than  a  man).  A  fall  upon  the  knees,  a 
trip,  or  an  attempt  to  prevent  a  fall  may  produce  this  frac- 
ture. Intracapsular  fracture  is  never  caused  by  direct  force 
unless  it  is  due  to  gunshot  violence.  The  aged  are  more 
liable  to  intracapsular  fracture  than  the  young  or  the  middle- 
aged,  because,  first,  the  angle  which  the  neck  forms  to  the 
axis  of  the  femur  becomes  less  obtuse  with  advancing  years, 
and  may  even  form  a  right  angle;  this  change  is  more  pro- 
nounced  in  women   than   in   men ;    secondly,  the   compact 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      373 

tissue  becomes  thinned  by  absorption,  the  canceUi  diminish, 
the  spaces  between  them  enlarge,  the  bony  partitions  of  the 
cancellous  portion  are  thinned  or  destroyed,  and  the  cancel- 
lous structure  becomes  fatty  and  degenerated. 

Syinptonis. — In  intracapsular  fracture  there  is  usually 
shortening  to  the  extent  of  from  half  an  inch  to  an  inch. 
Shortening  of  a  quarter  of  an  inch  does  not  count  in  diag- 
nosis,, for,  as  Hunt  shows,  one  limb  is  often  naturally  a  little 
shorter  than  the  other.  If  the  reflected  portion  of  the  capsule 
is  not  torn,  the  shortening  is  trivial  in  amount  or  is  entirely 
absent.  In  some  cases  shortening  gradually  or  suddenly 
increases  some  little  time  after  the  accident.  This  is  due  to 
separation  of  an  impaction,  tearing  of  the  previously  unlac- 
erated  capsular  reflection,  restoration  of  muscular  strength 
after  a  paresis,  or  absorption  of  the  head  of  the  bone.  Short- 
ening is  due  chiefly  to  pulling  up  of  the  lower  fragment  by 
the  hamstrings,  the  glutei,  and  the  rectus. 

Ez'crsion  exists,  spoken  of  as  "  helpless  eversion,"  though 
in  a  very  few  instances  the  patient  can  still  invert  the  leg. 
This  eversion  is  due  to  the  force  of  gravity,  the  limb  rolling 
outward  because  the  line  of  gravity  has  moved  externally. 
That  eversion  is  not  due  to  the  action  of  the  external  rotator 
muscles,  as  was  taught  by  Astley  Cooper,  is  proved  by  the 
fact  that  when  a  fracture  happens  in  the  shaft  below  the 
insertion  of  these  muscles  the  lower  fragment  still  rotates 
outward.  This  is  further  demonstrated  by  the  considera- 
tions that  the  internal  rotators  are  more  powerful  than  the 
external,  that  some  patients  can  still  invert  the  limb,  and 
that  eversion  persists  during  anaesthesia.^  In  some  unusual 
cases  inversion  attends  the  fracture.  Besides  shortening  and 
eversion,  the  leg  is  somewhat  flexed  on  the  thigh  and  the 
thigh  on  the  pelvis,  the  extremity  when  rolled  out  resting 
upon  its  outer  surface. 

1  Edmund  Owens  :  A  Manual  of  Anatomy. 


374  ^    MANUAL    OF  SURGERY. 

Loss  of  power  is  a  prominent  symptom  :  the  limb  can 
rarely  be  raised  or  inverted.  Pain  is  trivial  except  upon 
motion,  when  it  can  be  localized  in  the  joint.  Crepitus  often 
cannot  be  found,  either  because  the  fragments  cannot  be 
approximated  or  because  they  are  greatly  softened  by  fatty 
change.  To  obtain  crepitus  the  front  of  the  joint  must  be 
examined  while  the  limb  is  extended  and  rotated  inward. 
But  why  try  to  obtain  crepitus  ?  The  diagnosis  is  readily 
made  without  it,  in  many  cases  it  cannot  be  found,  and  the 
endeavor  to  obtain  it  inflicts  pain  and  may  effect  damage. 
These  fractures  offer  a  not  very  flattering  chance  of  repair, 
and  efforts  to  find  crepitus  may  injure  the  capsule  or  pull 
apart  an  impaction  (AUis). 

Altered  Arc  of  Rotation  of  the  Great  Trochanter  (Desault's 
sign). — The  pivot  on  which  the  great  trochanter  revolves  is 
no  longer  the  acetabulum,  and  the  great  trochanter  no  longer 
describes  the  segment  of  a  circle,  but  rotates  only  as  the  apex 
of  the  femur,  which  rotates  around  its  own  axis. 

Relaxation  of  tlie  fascia  lata  (Allis's  sign)  simply  means 
shortening.  The  fascia  lata  is  attached  to  the  ilium  and  the 
tibia  (ilio-tibial  band),  and  when  shortening  brings  the  tibia 
nearer  to  the  ilium  this  band  relaxes  and  permits  one  to 
push  more  deeply  inward  on  the  injured  side,  between  the 
great  trochanter  and  the  iliac  crest,  than  on  the  sound 
side. 

Ascent  of  tJie  Great  TrocJianter  above  Nelaton's  Line. — This 
line  is  taken  from  the  anterior  superior  iliac  spine  to  the 
most  prominent  part  of  the  ischial  tuberosity  (Fig.  51). 
In  health  the  great  trochanter  is  below,  and  in  intracapsular 
fracture  it  is  above,  this  line. 

Ascent  of  the  Trochanter  into  Bryant's  Triangle  (Fig.  51)- 
— Place  the  patient  recumbent,  carry  a  line  around  the  body 
on  a  level  with  the  anterior  superior  spines,  lay  down  Nela- 
ton's  line,  and  measure  the  base  of  the  triangle  from  the 


DISEASES  AXD   INJURIES    OF  BONES  AND  JOINTS.      375 

great  trochanter  to  the  perpendicular  hne  from   the   spine 
to  determine  the  amount  of  ascent. 

Morris  s  vicasiircmoit  shows  the  extent  of  inward  displace- 
ment.   Measure  from  the  median  line 
of  the  body  to  a  perpendicular  line 
drawn    through    the    trochanter    on 
each  side  of  the  body. 

Diagnosis. —  I ntracapsular  fracture 
without  separation  of  the  fragments 
maybe  mistaken  for  a  mere  contu-      ^  ,.,,.„       ,   „ 

-^  Fig.  51.— a  CD,  Bryants  Ilio- 

sion,  and  the  diagnosis  may  continue    femoral  Triangle;  ab,  Neiaton's 

,  1  1  r  L  Line  (Owen). 

obscure  unless  the  fragments  sepa- 
rate. Loss  of  function  in  contusion  is  rarely  complete  or 
prolonged,  although  occasionally  the  head  of  the  bone  is 
absorbed.  Intracapsular  fracture  may  be  confused  with 
extracapsular  fracture  or  with  a  dislocation  of  the  hip-joint. 
Extracapsular  fracture,  which  is  commonest  in  young  adults, 
results  from  direct  violence  over  the  great  trochanter ;  if 
non- impacted,  there  are  noted  shortening  of  from  one  and 
a  half  to  over  three  inches,  crepitus  over  the  great  trochanter, 
and  usually,  but  not  invariably,  eversion ;  if  impacted,  there 
is  less  eversion,  crepitus  is  almost  or  entirely  absent,  and  the 
shortening  is  limited  to  about  an  inch.  Great  tenderness 
exists  over  the  great  trochanter  in  both  impacted  and  non- 
impacted  fractures.  In  dislocation  on  the  dorsum  of  the 
ilium  the  patient  is  usually  a  strong  young  adult.  There 
are  inversion  (the  ball  of  the  great  toe  resting  on  the  instep 
of  the  sound  foot),  rigidity,  ascent  of  the  bone  above  Neia- 
ton's line,  and  shortening  of  from  one  to  three  inches. 
In  dislocation  into  the  thyroid  notch  there  is  possibly 
eversion,  but  it  is  linked  with  lengthening. 

Prognosis. — The  prognosis  is  not  very  favorable.  Old 
people  not  unusually  die.  In  impacted  fracture  bony  union 
may  occur  ;  in  non-impacted  fracture  fibrous  union  is  the  best 


376  A    MANUAL    OF  SURGERY. 

that  can  be  expected.  Non-union  is  not  unusual.  Perma- 
nent shortening  to  some  degree  is  inevitable,  and  the  function 
of  the  joint  is  sure  to  be  more  or  less  impaired.  It  will 
be  found  necessary  in  many  cases  for  the  patient  to  always 
employ  support  in  walking. 

Treatment. — In  treating  a  very  old  or  a  feeble  person  for 
intracapsular  fracture,  make  no  attempt  to  obtain  union. 
Keep  the  patient  in  bed  for  two  weeks,  give  lateral  support 
by  sand-bags,  tie  around  the  ankle  a  fillet,  to  which  attach 
a  weight  of  a  few  pounds,  and  hang  the  weight  over  the 
foot-board  of  the  bed.  When  pain  and  tenderness  abate, 
order  the  patient  to  get  into  a  reclining  chair,  and  permit 
him  very  soon  to  get  about  on  crutches.  If  hypostatic  con- 
gestion of  the  lungs  sets  in,  if  bed-sores  appear,  if  the  appe- 
tite and  digestion  utterly  fail,  or  if  diarrhoea  persists,  abandon 
attempts  at  cure  in  any  case  and  secure  for  the  sufferer 
sunshine  and  fresh  air.  Immobilize  the  fracture  as  thor- 
oughly as  possible  by  means  of  pasteboard  splints.  If  it  is 
determined  to  treat  the  case,  combine  extension  with  lateral 
support  by  means  of  sand-bags  and  the  extension  apparatus 
originally  devised  by  Gurdon  Buck.  Place  the  subject  on 
a  firm  mattress,  and  if  the  patient  be  a  man,  shave  the  leg. 
Cut  a  foot-piece  out  of  a  cigar-box,  perforate  it  for  a  cord, 
wrap  it  with  adhesive  plaster  as  shown  on  Plate  7,  Figures 
15,  16,  run  the  weight-cord  through  the  opening  in  the 
wood,  and  fasten  a  piece  of  plaster  on  each  side  of  the  leg, 
from  just  below  the  seat  of  fracture  to  above  the  malleolus 
(PL  7,  Fig.  14).  The  plaster  is  guarded  from  sticking  to 
the  malleoli  by  having  another  piece  stuck  to  it  at  each 
of  these  points.  Apply  an  ascending  spiral  reverse  bandage 
over  the  plaster  to  the  groin  (Fig.  52),  and  finish  the  band- 
age by  a  spica  of  the  groin.  Slightly  abduct  the  extremity. 
Put  a  brick  under  each  leg  of  the  bed  at  its  foot,  thus 
obtaining    counter-extension    by   the    weight   of  the    body. 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      377 

Run  a  cord  over  a  pulley  at  the  foot  of  the  bed,  and  get 
extension  by  the  use  of  weights.  From  ten  to  fifteen  pounds 
will  probably  be  necessary  at  first,  but  after  a  day  or  two 
from  six  to  eight  pounds  will  be  found  sufficient  (remember 
that  a  brick  weighs  about  five  pounds).  Make  a  bird's-nest 
pad  of  oakum  for  the  heel.    Take  two  canvas  bags,  one  long 


Fig.  52. — Adhesive  Plaster  Applied  to  Extension. 

enough  to  reach  from  the  crest  of  the  ilium  to  the  malleolus, 
the  other  long  enough  to  reach  from  the  perineum  to  the 
malleolus.  Fill  the  bags  three-quarters  full  of  dry  sand, 
sew  up  their  ends,  cover  the  bags  with  slips,  and  put  the 
bags  in  place  in  order  to  correct  eversion.  The  slips  may 
be  changed  every  third  or  fourth  day.  The  bowels  are  to 
be  emptied  and  the  urine  is  to  be  voided  into  a  bed-pan, 
unless  using  a  fracture-bed.  Maintain  extension  for  five  or 
six  weeks,  then  mould  pasteboard  splints  upon  the  part,  and 
keep  the  patient  in  bed  for  three  or  four  weeks  more.  In 
from  eight  to  ten  weeks  after  the  accident  the  patient  may 
get  about  on  crutches.  Union,  if  it  takes  place,  is  cartilagi- 
nous, and  not  bony,  and  there  is  bound  to  be  some  shorten- 
ing and  some  stiffness  of  the  joint.  Passive  motion  is  not 
made  until  after  eight  weeks  have  elapsed.  Professor  Senn 
claims  that  by  his  method  of  "  immediate  reduction  and 
permanent  fixation"  bony  union  is  obtained  in  fractures  of 
the  neck  of  the  femur  within  the  capsule.  He  "  places  the 
patient  in  the  erect  position,  causing  him  to  stand  with  his 
sound  leg  upon  a  stool  or  a  box  about  two  feet  in  height; 


378 


A   MANUAL    OF  SURGERY. 


in  this  position  he  is  supported  by  a  person  on  each  side 
until  the  dressing  has  been  applied  and  the  plaster  has  set. 
"Another  person  takes  care  of  the  fractured  limb,  which 
in  impacted  fractures  is  gently  supported  and  immovably 
held  until  permanent  fixation  has  been  secured  by  the  dress- 
ing. In  non-impacted  fractures  the  weight  of  the  fractured 
limb  makes  auto-extension,  which  is  often  quite  sufficient 
to  restore  the  normal  length  of  the  limb  ;  if  this  is  not  the 
case,  the  person  who  has  charge  of  the  limb  makes  traction 
until  all  shortening  has  been  overcome  as  far  as  possible, 
at  the  same  time  holding  the  limb  in  position,  so  that  the 
great  toe  is  on  a  straight  line  with  the  inner  margin  of  the 
patella  and  the  anterior  superior  spinous  process  of  the 
ilium.  In  applying  the  plaster-of- Paris  bandage  over  the 
seat  of  fracture  a  fenestrum,  corresponding  in  size  to  the 

dimensions  of  the  com- 
press with  which  the 
lateral  pressure  is  to  be 
made,  is  left  open  over 
the   great  trochanter. 

"  To  secure  perfect  im- 
mobility at  the  seat  of 
fractures,  it  is  not  only 
necessary  to  include  in 
the  dressing  the  fi'actured 
limb  and  the  entire  pelvis, 
but  it  is  absolutely  neces- 
sary to  also  include  the 
opposite  limb  as  far  as  the 
knee  and  to  extend  the  dressing  as  far  as  the  cartilage  of 
the  eighth  rib. 

"  The  splint  (Fig.  53)  is  incorporated  in  the  plaster-of- Paris 
dressing,  and  it  must  carefully  be  applied,  so  that  the  com- 
press, composed  of  a  well-cushioned  pad  with  a  stiff,  unyield- 


FiG.    53. — Senn's 
Apparatus  (Senn). 


Fig.  54. — Senn's  Appa- 
ratus Applied  (Senn). 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      2)79 

ing  back,  rests  directly  upon  the  trochanter  major,  and  the 
pressure,  which  is  made  by  a  set-screw,  is  directed  in  the 
axis  of  the  femoral  neck.  Lateral  pressure  is  not  applied 
until'  the  plaster  has  completely  set.  Syncope  should  be 
guarded  against  by  the  administration  of  stimulants. 

"As  soon  as  the  plaster  has  sufficiently  hardened  to  retain 
the  limb  in  proper  position,  the  patient  should  be  laid  upon 
a  smooth,  even  mattress,  without  pillows  under  the  head, 
and  in  non-impacted  fractures  the  foot  is  held  in  a  straight 
position  and  extension  is  kept  up  until  lateral  pressure  can 
be  applied. 

"  No  matter  how  snugly  a  plaster-of-Paris  dressing  is 
applied,  as  the  result  of  shrinkage  it  becomes  loose,  and 
without  some  means  of  making  lateral  pressure  it  would 
become  necessary  to  change  it  from  time  to  time  in  order 
to  render  it  efficient.  But  by  incorporating  a  splint  in  the 
plaster  dressing  (Fig.  54)  this  is  obviated,  and  the  lateral 
pressure  is  regulated,  day  by  day,  by  moving  the  screw,  the 
proximal  end  of  which  rests  on  an  oval  depression  in  the 
centre  of  the  pad." 

Extracapsular  Fracture. — The  line  of  extracapsular  frac- 
ture is  at  the  junction  of  the  neck  with  the  great  trochanter, 
and  is  partly  within  and  partly  without  the  capsule,  the 
fracture  being  generally  comminuted  and  often  impacted. 
The  cause  is  violent  direct  force  over  the  great  trochanter 
(as  by  falling  upon  the  side  of  the  hip).  This  fracture  is 
most  usual  in  strong  young  adults. 

Symptoms. — When  impaction  is  absent  there  is  marked 
crepitus,  which  is  manifested  most  when  the  fingers  are  put 
over  the  great  trochanter ;  there  are  great  pain,  swelling, 
and  ecchymosis ;  there  is  absolute  inability  on  the  part  of 
the  patient  to  move  the  limb,  and  passive  movements  cause 
great  pain ;  there  is  shortening  to  the  extent  of  at  least  one 
and  a  half  inches,  and  often  three  inches ;  and  there  is  abso- 


380  ^   MANUAL    OF  SURGERY. 

lute  eversion  with  slight  flexion  both  of  the  leg  and  the  thigh. 
All  these  symptoms  follow  violent  direct  lateral  force.  In 
the  impacted  form  of  extracapsular  fracture,  in  addition  to 
the  aid  given  the  surgeon  by  the  history,  there  is  severe 
pain  which  is  intensified  by  movement  or  pressure ;  shorten- 
ing exists  to  the  extent  of  one  inch  at  least,  which  is  not 
corrected  by  extension ;  there  is  also  great  loss  of  function  ; 
and  whereas  the  limb  may  be  straight  or  even  inverted, 
it  is  usually  everted.  Crepitus  cannot  be  obtained  without 
improper  violence,  and  the  trochanter  moves  in  a  large  arc 
of  rotation,  although  it  is  in  Bryant's  triangle  and  above 
Nelaton's  line. 

Treatment. — In  treating  extracapsular  fracture,  make  ex- 
tension, raise  the  foot  of  the  bed,  and  apply  the  extension 
apparatus  with  sand-bags  for  four  weeks ;  then  apply  a 
plaster  dressing  and  get  the  patient  up  on  crutches.  Remove 
the  plaster  at  the  end  of  four  weeks.  In  impacted  fracture 
use  a  moderate  force  in  extending,  but  never  violently  pull 
the  bones  apart. 

Fracture  of  the  Great  Trochanter. — This  process  may 
be  (i)  broken  off  without  any  other  injury,  but  in  most  cases 
(2)  the  line  of  fracture  runs  through  the  trochanter,  and 
leaves  one  portion  of  the  trochanter  attached  to  the  head 
and  neck  and  the  other  part  attached  to  the  shaft.  The 
cause  is  violent  direct  force  over  the  great  trochanter. 

Symptoms  and  Treatment. — The  symptoms  of  the  second 
form  are  similar  to  those  of  extracapsular  fracture.  On 
rotating  the  femur  the  lower  part  of  the  trochanter  moves 
with  it,  but  not  the  upper.  The  lower  fragment  goes  upward 
and  backward  and  projects  by  the  side  of  the  sciatic  notch. 
There  are  shortening,  eversion,  crepitus,  and  altered  position 
of  the  trochanter.  The  symptoms  of  the  first  form  resemble 
those  of  epiphyseal  separation.  The  treatment  of  the  second 
form    is    like  that    in    extracapsular    fracture,  and  the  first 


DISEASES  AND  INJURIES   OF  BONES  AND  JOINTS.      38 1 

form    is   treated    like    separation    of  the    epiphysis    of    the 
trochanter. 

Separation  of  the  upper  epiphysis  of  the  femoral  head 
is  a  very  rare  result  of  accident ;  it  occurs  most  often  from 
disease  and  in  youth. 

Symptoms  and  Treatment. — The  symptoms  are  like  those 
of  fracture  of  the  neck,  except  that  the  crepitus  is  soft. 
The  treatment  is  extension  as  above  directed. 

Separation  of  the  epiphysis  of  the  great  trochanter  is 
a  very  rare  accident.  The  cause  is  direct  violence,  and  the 
injury  occurs  only  in  youth. 

Symptoms. — The  trochanter  is  found  to  have  ascended 
and  passed  posteriorly;  there  is  no  shortening;  all  the 
motions  of  the  hip-joint  can  be  obtained;  if  the  thigh  is 
flexed,  abducted,  and  rotated  externally,  and  the  fragment 
pushed  down  and  forward,  crepitus  is  obtained — soft  in 
epiphyseal  separation,  hard  in  fracture. 

Treatment. — In  treating  separation  of  the  epiphysis  of  the 
great  trochanter,  flex  the  leg  on  the  thigh  and  the  thigh  on 
the  pelvis,  place  the  extremity  upon  its  outer  surface,  keep  it 
fixed  by  some  form  of  retentive  apparatus,  and  try  to  draw 
the  trochanter  downward  and  forward  by  adhesive  strips  or 
by  a  pad  and  bandage.  Some  degree  of  lameness  is  inevi- 
table, even  after  Bryant's  extension.  Bryant's  extension 
directly  upward  may  admit  of  the  trochanter  being  pulled 
downward  upon  the  bone.  Dressing  must  be  applied  for 
six  weeks,  and  crutches  and  pasteboard  splints  are  used  for 
four  weeks  more. 

2.  Fractures  of  the  shaft  of  the  femur  may  affect  any 
portion  of  the  shaft,  but  especially  the  middle  third,  and  may 
occur  at  any  age.  The  caiise  of  fractures  in  the  upper  third 
is  usually  indirect  force;  fractures  in  the  lower  third  are  due 
to  direct  force;  and  in  fractures  of  the  middle  third  these  two 
causes  are  about  equally  potential.     Fracture  from  muscular 


382 


A    MANUAL    OF  SURGERY. 


action  occasionally  occurs.     Oblique  fracture  is   the    usual 
variety. 

Symptoms. — The  chief  symptom  in  fracture  of  the  shaft 
of  the  femur  is  great  displacement,  except  when  impaction 
occurs  or  when  the  break  is  in  a  child  and  the  periosteum  is 
untorn.  As  a  rule,  the  lower  fragment  is  drawn  up  and  is 
posterior  and  somewhat  to  the  inside  of  the  upper  fragment, 
and  undergoes  external  rotation  (the  drawing  up  is  due  to 
the  rectus  and  hamstrings ;  the  passing  in  is  due  to  the 
adductor  muscles;  the  rotation  outward  arises  from  the 
weight  of  the  limb).  In  fracture  of  the  upper  third  the 
upper  fragment  is  apt  to  be  thrown  strongly  forward  and 
outward.  Some  attribute  this  to  the  action  of  the  psoas, 
iliacus,  and  external  rotator  muscles,  but  Dr.  Allis  thinks  it 
is  due  to  the  lower  fragment  pushing  the  upper  fragment 
into  this  position.  There  is  complete  loss  of  function,  the 
thigh  and  leg  being  semiflexed  and  everted.  There  are 
shortening  to  the  extent  of  two  or  three  inches,  pain  on 
movement,  preternatural  mobility,  crepitus,  and'  obvious 
deformity,  and  the  ends  of  the  fragments  can  be  felt.  In 
impaction  there  is  shortening  with  altered  axis  of  the  limb. 


Fig.  55. — Dressing  of  Fracture  of  the   Femur  in  the  Upper  Third  with  Extension  upon 
a  Double  Inclined  Plane  (Agnew). 

Treatment. — In  fractures  of  the  shaft  of  the  femur  some 
amount  of  permanent  shortening  is  almost  inevitable.  In  frac- 
tures of  the  upper  third,  use  Agnew's  plan — namely,  a  double 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      383 


inclined  plane  with  extension  in  the  axis  of  the  partly-flexed 
thigh  (Fig-.  55).  If,  notwithstanding  position  and  extension, 
the  upper  fragment  projects,  push  it  into  place  and  bind  short 
splints  upon  the  limb.  Extension  is  continued  for  four  weeks, 
a  plaster-of-Paris  bandage  being  used  for  four  weeks  more,  the 
patient  being  then  allowed  to  get  about  on  crutches.  Some 
surgeons,  in  fractures  of  the  upper  third,  apply  a  plaster-of- 
Paris  .bandage  to  the  leg,  thigh,  and  pelvis,  extension  being 
made  from  the  foot  while  the  dressing  is  being  applied.  The 
anterior  splint  of  Nathan  R.  Smith  is  much  used  in  the 
South  in  treating  fractures 
of  the  shaft  and  the  upper 
extremity  (Fig.  56).  In 
fractures  of  the  middle 
third  and  upper  part  of  the 
lower  third  of  the  shaft, 
use  the  extension  appara- 
tus (PI.  7,  Fig.  14)  with 
the  sand-bags,  running  the 
plaster  to  just  below  the 
seat  of  the  fracture,  and 
the  roller  bandage  to  a 
little  above  this  point.  Ex- 
tension is  to  be  continued 
for  four  weeks,  and  the  plaster-of-Paris  bandage  is  used  for 
four  weeks  more.  In  fractures  of  the  lower  part  of  the 
lower  third  of  the  shaft,  use  a  double  inclined  plane  (PL  7, 
Fig.  2)  alone.  A  Mclntyre  splint  (Fig.  57)  is  a  useful  form 
of  double  inclined  plane.  At  the  end  of  four  weeks  apply 
plaster,  which  is  to  be  worn   for  four  weeks. 

Fracture  just  above  the  Condyles. — The  liiic  of  this 
fracture  is  well  above  the  epiphyseal  line.  The  femoral 
artery  is  in  danger  from  the  fragments.  The  causL\  as  a 
rule,    is    direct   violence.     Indirect  force  is    sometimes    re- 


FiG    56. — Smith  Anterior  Splint. 


384 


A   MANUAL    OF  SURGERY. 


Sponsible    (falls    upon    the    feet).      The    knee-joint   may  be 

opened. 

Symptoms. — The  upper  end  of  the  lower  fragment  passes 

back  into  the  popliteal  space  and  is  drawn  upward  (rectus, 

hamstrings,  gastrocnemius,  and  popliteus),  the  upper  frag- 
ment passes  inward,  and  the  deformity  is 
very  manifest.  There  are  shortening,  crepi- 
tus, and  mobility.  The  ends  of  the  frag- 
ments can  be  felt.  If  the  force  has  been 
very  great,  a  T-fracture  results,  and  in  this 


Fig.  57. — Mclntyre  Splint  (Tiemann). 


the  knee  is  broadened  and  crepitus  is  got  by  moving  the 
condyles,  one  up  and  the  other  down. 

Treatment. — In  treating  a  fracture  above  the  condyles, 
place  the  limb  on  a  double  inclined  plane  for  five  weeks, 
then  start  passive  motion  once  every  other  day,  restoring 
the  limb  to  the  splint  after  the  movements  are  completed. 
At  the  end  of  eight  weeks  after  the  accident,  remove  the 
dressings,  and,  if  the  knee-joint  be  stiff,  use  for  some  time 
massage,  motions,  hot  and  cold  douches,  ichthyol  inunctions, 
etc.  Bryant  treats  this  fracture  in  extension,  cutting  the 
tendo  Achillis,  if  necessary,  to  amend  deformity. 

Fracture  Separating-  Either  Condyle. — The  cause  of  this 
fracture  is  direct  force. 

Symptoms  and  Treatment. — The  broken  piece  is  drawn 
upward,  the  leg  bends  toward  the  injury,  crepitus  exists,  the 


DISEASES  AND   INJURIES    OF  BONES  AND  JOINI^S.      385 

knee  is  much  broadened,  there  is  no  shortening,  and  consider- 
able sweUing  is  sure  to  arise.  In  treating  a  fracture  separating 
either  condyle,  use  a  double  inclined  plane  as  directed  above. 

Longitudinal  fractures  run  up  from  the  knee-joint.  The 
cause  is  a  fall  upon  the  feet  or  the  knees. 

Symptoms  and  Treatment. — The  symptoms  of  longitudinal 
fracture  are  often  obscure.  The  femur  is  broadened  when 
the  knee  is  flexed.  The  split  is  detected  between  the  con- 
dyles. The  treatment  is  the  straight  position  in  plaster  for 
eight  weeks. 

Separation  of  the  lower  epiphysis  occurs  only  before 
the  twenty-first  year. 

Symptoms. — The  symptoms  in  separation  of  the  lower 
epiphysis  are  like  those  of  fracture,  but  crepitus  is  moist. 
The  danger  is  that  the  growth  of  bone  will  be  stunted. 

Treatment. — The  treatment  for  separation  of  the  lower 
epiphysis  is  a  double  inclined  plane  as  above  directed. 

Fracture  of  the  patella  is  a  very  common  accident.  The 
cause  is  direct  force  (producing  vertical,  star-shaped,  or 
oblique  lines  of  fracture)  or  muscular  action  (producing  a 
transverse  line  of  fracture). 

Fractures  of  the  Patella  by  Muscular  Action. — The 
knee-cap  is  more  often  broken  by  muscular  action  than  is 
any  other  bone.  When  the  knee  is  partly 
flexed  the  middle  third  of  the  patella  rests 
upon  the  condyles  of  the  femur  and  the 
upper  third  of  the  knee-cap  projects  above 
them;  when  in  this  position  a  contraction 
of  the  quadriceps  may  easily  cause  a  fracture 
near  the  centre  of  the  bone  (Figr.  c8).     Both      Fig.  58— Fracture  of 

%         ,.       -  the  Patella  by  Muscu- 

patellse  may  be  broken  at  once.    In  this  form    lar  Action  (Treves). 
of  fracture  the  joint,  and  often  the  prepatellar  bursa,  is  opened. 
Symptoms. — The  symptoms  in  fractures  by  muscular  action 
are — rapid  and  enormous  swelling,  due  to  the  effusion  first  of 

25 


386  A   MANUAL    OF  SURGERY. 

blood  and  then  of  synovia  and  inflammatory  products  into 
and  around  the  joint;  absolute  inability  to  raise  the  limb 
from  the  bed.  The  fragments  are  widely  separated,  this 
separation  being  distinctly  manifest  to  the  touch  unless 
swelling  is  great.  The  separation  is  accentuated  by  flexion 
of  the  leg.  Crepitus  is  detected  if  the  upper  fragment  can 
be  pushed  down  until  it  touches  the  lower  piece,  but  if 
swelling  is  great  this  cannot  be  done.  Union,  if  it  occurs, 
will  be  ligamentous,  and  not  bony,  and  if  the  patient  gets 
about  too  soon,  apparently  well-united  fragments  will  by 
degrees  stretch  far  asunder. 

Transverse  Fractures  of  the  Patella. — Treatment. — If  the 
swelling  in  transverse  fracture  of  the  patella  be  so  great  as 
to  prevent  approximation  of  the  fragments,  reduce  it  by 
bandaging  for  a  day  or  two,  by  using  ice-bags  and  lead- 
water  and  laudanum,  or  by  aspirating  the  joint.  When  the 
swelling  diminishes,  bring  the  two  fragments  into  apposition, 
pull  them  together  by  adhesive  plaster,  and  put  on  a  well- 
padded  posterior  splint.  Run  a  piece  of  adhesive  plaster 
over  the  upper  end  of  the  upper  fragment,  draw  the  bone 
down,  and  fasten  the  plaster  behind  and  below  the  joint. 
Run  another  piece  of  plaster  over  the  lower  end  of  the 
lower  fragment,  draw  the  bone  up,  and  fasten  the  plaster 
behind  and  above  the  joint.  A  third  piece  is  run  over  the 
junction  of  the  fragments  to  prevent  tilting.  Agnew's  splint 
admirably  accomplishes  this  approximation  (PI.  7,  Figs.  11, 
12).  A  bandage  holds  the  splint  in  place,  and  may  be  carried 
around  the  knee  by  figure-of-8  turns.  The  heel  is  sometimes 
raised  upon  a  pillow  so  as  to  extend  the  leg  and  to  semiflex 
the  thigh,  but  this  is  not  essential.  Remove  and  reapply 
the  dressing  every  few  days,  as  it  inevitably  becomes  loose. 
At  the  end  of  three  weeks  remove  the  splint  permanently 
and  apply  a  plaster-of- Paris  dressing  from  just  above  the 
ankle  to  the  middle  of  the  thigh.    The  dressing  is  to  be  worn 


DISEASES  AND   IXJURIES   OF  BONES  AND  JOINTS.       387 

for  five  weeks.  At  the  end  of  eight  weeks  let  the  patient 
walk  with  canes,  the  joint  being  kept  fixed  for  four  weeks 
more  by  pasteboard  sphnts  or  by  a  Hght  plaster-of-Paris 
bandage.  For  one  year  after  removing  the  sphnts  and 
plaster  a  lacing  knee-cap  and  a  posterior  splint  should  be 
worn  to  support  the  joint.  The  plan  of  prolonged  retention 
renders  more  or  less  joint-stiffness  a  certain  occurrence,  but 
this  is- less  of  an  impediment  than  the  wide  separation  of  the 
fragments  that  inevitably  attends  an  early  use  of  the  joint. 

Malgaigne's  hooks  (Fig.  59),  if  employed  to  treat  these 
fractures,  are  to  be  inserted  with  the  full  antiseptic  care  of 
an  ordinary  surgical  opera- 
tion. Insert  the  lower  hooks  <^|^^ 
just  below  the  point  of  the 
patella,  entering  them  under 
its  edge,  press  the  fragments 
together,  draw  up  the  skin 
over  the  upper  fragment  to 
prevent  puckering,  and  insert 
the  upper  hooks  with  force  just  above  the  upper  fragment, 
letting  the  points  of  the  hooks  bear  upon  the  bone.  Lock 
or  screw  the  hooks  together,  dress  with  antiseptic  gauze, 
and  apply  a  posterior  splint.  Remove  the  hooks  in  three 
weeks,  and  treat  with  plaster  as  in  the  preceding  case  when 
the  special  splint  was  removed. 

Among  other  plans  of  treatment  may  be  mentioned  wiring 
the  fragments  (see  Operations  tipon  Bones) ;  encircling  the 
fragments  with  a  subcutaneous  silk  ligature ;  passing  a  pin 
through  the  tendon  of  the  quadriceps,  another  through  the 
ligament  of  the  patella,  and  approximating  the  two  by 
figure-of-8  turns  with  a  silk  cord,  thus  drawing  together  the 
fragments. 

Fractures  of  the  patella  by  direct  force  are  vertical, 
stellate,  oblique,  or  V-shaped,  and  are  often  incomplete. 


Fig.  59. — Malgaigne's  Hooks. 


388  A   MANUAL    OF  SURGERY. 

Symptoms. — Fractures  of  the  patella  by  direct  force  are 
indicated  by  discoloration,  swelling,  great  difficulty  in  move- 
ment, and  much  pain.  There  may  or  may  not  be  crepitus, 
and  rarely  is  there  separation  of  the  fragments.  Bony  union 
occurs  in  these  fractures. 

Treatment. — Fracture  by  direct  force  requires  a  posterior 
splint,  the  local  use  of  lead-water  and  laudanum,  and  the 
application  of  a  bandage.  If  there  is  any  separation,  approx- 
imate the  fragments  by  bandages  and  compresses.  The 
danger  in  these  cases  is  not  non-union,  but  is  ankylosis  ; 
hence,  begin  passive  motion  of  the  knee-joint  in  the  fourth 
week  after  the  accident.  Remove  the  dressings  at  the  end 
of  six  weeks,  and  let  the  patient  at  once  get  about. 

Fractures  of  the  Leg-. — In  leg-fractures  both  bones  or 
only  one  bone  may  be  broken. 

Fractures  of  the  tibia  are  divided  into  (i)  fractures  of  the 
upper  end  ;  (2)  separation  of  the  upper  epiphysis ;  (3)  frac- 
tures of  the  shaft;  (4)  fractures  of  the  lower  end;  and  (5) 
separation  of  the  lower  epiphysis. 

Fractures  of  the  upper  end  of  the  tibia  are  uncommon. 
They  may  be  transverse,  oblique,  or  vertical  running  into 
the  joint.     The  cause  is   direct  violence. 

Symptoms. — In  fracture  of  the  upper  end  of  the  tibia  there 
is  contusion  of  the  soft  parts.  In  a  transverse  fracture  there 
are  mobility  and  crepitus,  but  there  is  little  displacement. 
In  oblique  fracture  crepitus  and  mobility  are  marked  and 
the  axis  of  the  limb  is  altered.  In  vertical  fractures  enter- 
ing the  joint  there  is  great  swelling  of  the  knee-joint.  In 
comminuted  fractures,  which  exhibit  marked  signs,  union  is 
readily  obtained,  but  if  the  joint  has  been  damaged  stiffness 
is  sure  to  ensue. 

Treatment. — In  treating  fractures  of  the  upper  end  of  the 
tibia,  employ  a  double  inclined  plane  in  the  form  of  a 
Mclntyre  splint  (Fig.  57)  or  in  the  form  of  a  fracture-box 


DISEASES  AND   INJURIES   OE  BONES  AND  JOINTS.      389 

(PI.  7,  Fig.  i).  Lead-water  and  laudanum  and  cold  are 
applied  about  the  knee-joint.  At  the  end  of  the  fourth 
week  begin  passive  motion,  reapplying  the  splint  after  each 
daily  seance.  In  six  weeks  let  the  patient  get  about,  first  with 
crutches,  then  with  a  cane,  then  without  any  artificial  support. 

Separation  of  the  Upper  Epiphysis  of  the  Tibia. — There 
is  only  one  recorded  case  (Pick). 

Fractures  of  the  Shaft  of  the  Tibia. — The  cause  of  these 
fractures  is  direct  force.  The  fracture  is  generally  trans- 
verse in  the  upper  part  of  the  bone  and  oblique  in  the  lower 
part  (Pickering  Pick). 

Symptoms. — In  transverse  fracture  of  the  shaft  of  the  tibia 
there  is  no  deformity,  and  the  support  of  the  fibula  may  even 
permit  of  walking ;  there  is  fixed  pain  ;  there  may  or  may 
not  be  inequality  of  fragments  felt  by  the  finger ;  and  there 
are  crepitus,  mobility,  and  often  linear  ecchymosis.  In  oblique 
fractures  there  usually  exist  crepitus,  a  little  mobility,  and 
some  deformity.  The  deformity  depends  on  the  direction 
of  the  line  of  fracture,  and,  as  this  line  is  usually  from  above 
downward,  inward,  and  a  little  forward,  the  lower  fragment 
usually  passes  behind  the  upper  fragment  and  rotates  inward. 

Trcatmoit. — In  treating  fractures  of  the  shaft  of  the  tibia, 
if  there  be  much  swelling,  put  the  limb  in  a  fracture-box 
(PL  7,  J^ig.  I  ;  PI.  8,  Fig.  6)  and  apply  lead-water  and  lauda- 
num. A  silicate-of-soda  or  a  plaster-of-Paris  dressing  is 
applied  when  the  swelling  subsides,  or  the  dressing  is  used 
at  once  if  swelling  is  slight.  The  patient  gets  about  on 
crutches.  The  dressing  is  removed  in  six  weeks,  and  the 
patient  goes  about  for  one  week  on  crutches,  lightly  using 
the  foot,  and  then  for  one  week  with  a  cane.  At  the  end  of 
eight  weeks  the  leg  may  be  used,  but  not  too  much  at  first. 

Fractures  of  the  Lower  End  of  the  Tibia :  Fracture 
of  the  Inner  Malleolus. — The  cause  of  fracture  of  the  inner 
malleolus  is  direct  force. 


390  A   MANUAL    OF  SURGERY. 

Symptoms  and  Treatmerit. — The  symptoms  of  fracture  of 
the  inner  malleolus  are  some  downward  displacement, 
depression  above  the  fragment,  mobility,  and  crepitus.  The 
trcatmoit  is  to  push  the  fragment  into  place  and  use  side- 
splints  or  a  fracture-box  for  two  weeks,  when  a  plaster-of- 
Paris  or  a  silicate  dressing  may  be  substituted  and  the 
patient  be  ordered  to  use  crutches.  Remove  the  plaster 
four  weeks  after  it  is  applied,  and  direct  the  patient  to  grad- 
ually bear  his  weight  upon  the  leg,  as  outlined  above. 

Separation  of  the  lower  epiphysis  of  the  tibia  is  a  very 
rare  accident.    The  treatment  is  a  fixed  dressing  for  six  weeks. 

Fracture  of  the  fibula  alone  is  commoner  by  far  than 
is  fracture  of  the  tibia  alone.  Fractures  in  the  upper  two- 
thirds,  which  are  rare,  are  usually  due  to  direct  force.  Frac- 
tures in  the  lower  third  are  frequent,  and  they  arise  from 
indirect  force. 

Fractures  of  the  Upper  Two-thirds  of  the  Fibula. — In 
these  fractures  the  cause  is  direct  force. 

Symptoms. — In  fracture  of  the  upper  two-thirds  of  the 
fibula  the  patient  can  often  walk.  The  bone  is  deeply  situ- 
ated, and  displacement  cannot  often  be  made  out.  There  is  a 
fixed  pain  which  is  intensified  by  movement  and  by  pressure. 
Pressure  upon  the  lower  fragment  does  not  move  the  uppei 
fragment.  Crepitus  is  sometimes  felt,  and  a  linear  ecchy- 
mosis  is  apt  to  appear.  The  bone  bends  normally,  hence 
slight  mobility  is  of  no  value  diagnostically. 

Treatment. — In  treating  a  fracture  of  the  upper  two-thirds 
of  the  fibula,  apply  a  plaster-of-Paris  or  a  silicate  bandage 
and  direct  that  it  be  worn  for  six  weeks.  Weight  is  not  to 
be  put  upon  the  foot  for  eight  weeks  after  the  accident. 

Fractures  of  the  Lower  Third  of  the  Fibula. — In  these 
fractures  the  cause  is  indirect  force,  especially  twists  of  the 
foot.  Forcible  inversion  of  the  foot  pulls  upon  the  external 
lateral  ligament  and  the  external  malleolus,  forces  the  fibula 


DISEASES  AXD   IXJURIES   OF  BONES  AND  JOINTS.      39 1 

outward,  and  tends  to  break  it,  the  lower  fragment  being  dis- 
placed outward.  Forcible  eversion  pulls  the  internal  lateral 
ligament  off  from  the  inner  malleolus  (often  breaks  the  mal- 
leolus) and  fractures  the  fibula  above  the  ankle,  the  bone 
being  displaced  inward. 

Symptonis. — In  the  lower  third  of  the  fibula  the  bone  is 
superficial,  and  the  irregularity  of  a  fracture  is  manifest  to 
the  touch.  There  is  localized  pain  which  is  increased  by 
pressure  or  by  motion.  Crepitus  may  exist.  Deformity  is 
often  exhibited  by  the  position  of  the  foot. 

Pott's  fracture,  which  is  a  fracture  of  the  lower  fifth  of 
the  fibula  accompanied  by  outward  dislocation  of  the  foot, 
is  due  to  powerful  eversion  of  the  foot.  This  outward 
dislocation  is  rendered  possible  by  rupture  of  the  deltoid 
ligament  or — what  is  far  commoner — by  the  tearing  off  of 
a  portion  of  the  internal  malleolus. 

Treatment. — In  fractures  of  the  lower  third  of  the  fibula, 
after  reducing  displacement,  place  the  limb  in  a  fracture-box 
containing  a  soft  pillow.  A  bird's- nest  pad  of  cotton  or 
oakum  is  made  for  the  heel  (PI.  8,  Fig.  6).  A  fillet  around 
the  ankle  fastens  the  foot  to  the  foot-piece  of  the  box ;  a  pad 
of  oakum  rests  between  the  foot-piece  and  the  sole.  If 
dressing  Pott's  fracture,  put  a  compress  above  the  inner 
malleolus  and  another  compress  below  the  outer  malleolus. 
Close  the  sides  of  the  box  and  tie  them  together  with  a 
bandage.  Swing  the  box,  if  desired,  on  a  gallows.  Every 
day  let  down  the  sides  of  the  box  and  rub  the  leg,  the  ankle, 
and  the  foot  with  alcohol.  In  ten  days  apply  a  plaster-of- 
Paris  bandage  and  let  the  patient  get  about  on  crutches. 
Remove  the  plaster  at  the  end  of  the  fifth  week  after  the 
accident,  and  let  the  patient  go  about  with  crutches  for  one 
week  and  with  a  cane  for  a  week  longer. 

Some  surgeons  dress  Pott's  fracture  with  a  Dupuytren 
splint.    This  is  a  straight  splint  (PL  7,  P'ig.  9)  which  reaches 


392  A    MANUAL    OF  SURGERY. 

from  the  head  of  the  tibia  to  or  below  the  toes.  This  splint 
is  padded,  and  a  pyramidal  pad  with  the  base  down  is  laid 
upon  the  inner  surface  of  the  leg,  above  the  inner  malleolus, 
the  splint  being  put  upon  the  inner  surface  of  the  leg,  over 
the  pad.  The  splint  is  fastened  as  shown  on  Plate  7  (Fig.  9), 
and  the  leg  is  semiflexed  upon  the  thigh  and  is  laid  upon  its 
outer  surface  on  a  pillow.  After  ten  days  apply  the  plaster- 
of-Paris  bandage,  which  is  to  be  worn  as  above  directed. 

Fracture  of  both  bones  of  the  leg,  a  very  common  in- 
jury, is  often  compound,  and  is  not  unusually  comminuted. 
Fractures  by  direct  force,  such  as  blows  or  kicks,  are  com- 
monest in  the  upper  half  of  the  leg.  Fractures  by  indirect 
force,  as  by  falls,  are  commonest  in  the  lower  half  of  the  leg. 
In  fractures  from  indirect  force  the  tibia  breaks  first,  and 
then  the  fibula  breaks  at  a  higher  level.  The  point  of  greatest 
liability  to  fracture  from  indirect  force  is  the  junction  of  the 
lower  and  middle  thirds.  Fractures  of  the  leg  are  usually 
oblique,  but  they  may  be  transverse  if  arising  from  direct 
force.  Spiral,  torsion,  or  V-shaped  fractures  and  longitudinal 
breaks  sometimes  occur.  In  oblique  fractures,  as  a  rule,  the 
line  of  fracture  runs  downward,  inward,  and  a  little  forward. 

Symptoms. — Fracture  of  both  bones  of  the  leg  is  easy  of 
recognition.  By  running  the  finger  along  the  crest  of  the 
tibia  displacement  will  be  found,  except  in  transverse  frac- 
tures, when  it  may  not  occur.  The  common  displacement 
is  for  the  lower  fragment  to  ascend  and  pass  behind  the 
lower  end  of  the  upper  fragment  and  to  rotate  a  little  out- 
ward, and  for  the  upper  fragment  to  project  in  front.  This 
ascent  is  due  to  the  action  of  the  gastrocnemius  and  soleus 
muscles.  If  the  line  of  fracture  is  in  a  direction  the  reverse 
of  that  which  is  usual,  the  lower  fragment  ascends  in  front 
of  the  lower  end  of  the  upper  fragment.  In  fracture  of  both 
bones  there  are  mobility,  crepitus,  pain,  and  inability  to  walk. 
In  fractures  from  direct  force  there  is  more  or  less  damage 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      393 

to  the  soft  parts.  A  fracture  near  the  ankle  is  distinguished 
from  "a  dislocation  by  the  fact  that  the  deformity  is  easily 
reduced,  but  it  tends  to  recur  in  the  fracture,  and,  further, 
that  in  a  fracture  the  relations  of  the  malleoli  to  the  tarsus 
are  unaltered. 

Treatment. — In  treating  a  simple  fracture,  reduce  by  ex- 
tension and  counter-extension,  and  use  a  fracture-box  (PI.  7, 
Fig.  i)  as  in  Pott's  fracture  (p.  391),  though  the  compresses 
are  not  required.  If  the  soft  parts  are  bruised,  use  lead-water 
and  laudanum  ;  if  they  are  lacerated,  apply  antiseptic  dress- 
ings. The  fracture-box  may  be  swung  upon  a  gallows.  After 
three  weeks  apply  plaster-of-Paris  or  silicate-of-soda  dress- 
ing and  let  the  patient  sit  up  in  a  chair  daily  for  one  week ; 
at  the  end  of  this  time  the  patient  may  get  about  with 
crutches.  At  the  end  of  six  weeks  after  the  accident,  remove 
the  plaster,  and  let  the  sufferer  get  about  with  crutches  for 
two  weeks  and  with  a  cane  for  two  weeks  more.  Dr.  Brin- 
ton  dresses  a  fracture  of  both  bones  of  the  leg  for  two  weeks 
in  a  fracture-box,  for  two  weeks  in  side-splints,  and  for  two 
weeks  in  an  immovable  dressing.  If  the  fracture  is  com- 
pound, asepticize  thoroughly,  make  a  counter-opening,  insert 
a  drainage-tube,  dress  with  bichloride  gauze,  apply  a  plaster 
bandage,  and  cut  trap-doors  over  the  openings  of  the  tube 
(see  Fig.  47).  Remove  the  tube,  as  a  rule,  in  about  forty- 
eight  hours;  but  the  patient's  temperature  is  a  better  guide 
than  time. 

Fractures  of  the  bones  of  the  foot  are  rather  rare  acci- 
dents. Owing  to  the  number  of  the  bones  and  to  the 
elasticity  of  their  connections,  the  force  of  blows  and  falls 
is  spread  and  dissipated.  Fractures  from  direct  force  are 
often  compound.  The  cause  of  fracture  of  either  the  scaph- 
oid, the  cuboid,  or  any  of  the  cuneiform  bones  is  direct 
force.  Fractures  of  the  os  calcis  and  astragalus  arise,  as 
a  rule,  from  indirect  force,  such  as  falls,  but  the  calcaneum 


394  ^    MANUAL    OF  SURGERY. 

may  be  broken  by  direct  violence.  In  rare  instances  the 
OS  calcis  has  been  broken  by  contraction  of  the  great  calf- 
muscles. 

Syniptoins. — In  fracture  of  the  os  calcis  there  are  severe 
pain,  swelling-,  crepitus,  mobility,  often  an  apparent  widening 
of  the  bone,  not  unusually  a  loss  of  the  arch  of  the  foot 
(Pick).  In  some  cases  the  posterior  fragment  is  drawn  up 
by  the  calf-muscles,  and  in  other  cases  there  is  deformity. 
In  fracture  of  the  astragalus  displacement  may  occur  which 
resembles  that  of  a  dislocation.  Crepitus  may  or  may  not 
be  detected.  If  crepitus  cannot  be  found,  it  is  not  certain  that 
a  fracture  is  present,  though  the  patient  may  be  unable  to 
stand  and  there  may  be  swelling  and  pain  on  pressure. 
Fractures  of  the  other  bones  are  hard  to  detect.  There 
may  or  may  not  be  crepitus,  which,  if  it  exists,  is  hard  to 
localize;  there  are  pain  on  standing  and  on  pressure  and 
bruising  of  the  soft  parts. 

Treatment — To  treat  a  fracture  of  the  os  calcis  when  no 
deformity  exists,  use  a  fracture-box  for  two  weeks  ;  maintain 
the  foot  at  a  right  angle  to  the  leg;  apply  lead- water  and 
laudanum  ;  then  put  on  an  immovable  dressing,  and  let  it 
be  worn  for  four  weeks.  In  fracture  of  the  os  calcis  with 
drawing  up  of  the  posterior  fragment,  flex  the  leg  upon  the 
thigh,  extend  the  foot,  and  maintain  this  position  by  means 
of  a  band  around  the  thigh,  the  band  being  fastened  by  means 
of  a  cord  to  a  slipper  (PI.  9,  Fig.  5),  the  leg  resting  upon  its 
outer  side.  At  the  end  of  two  weeks  apply  plaster,  and  let  it 
be  worn  for  four  weeks.  If  the  projecting  fragment  of  the  os 
calcis  cannot  be  forced  into  place,  and  if  it  makes  dangerous 
pressure  upon  the  skin,  excise  it ;  if  it  does  not  make 
pressure  which  threatens  sloughing,  place  the  joint  in  a 
position  favorable  for  ankylosis,  and  immobilize.  In  a  frac- 
ture of  the  astragalus,  use  a  fracture-box  and  then  an  im- 
movable dressing,  as  in  fracture  of  the  os    calcis   without 


DISEASES  AND    INJURIES    OF  BONES  AND  JOINTS.       395 

deformity.  Fractures  of  the  other  bones  of  the  tarsus  are 
almost  invariably  compound,  and  the  injury  may  require 
drainage  and  immovable  dressing,  excision,  or  even  ampu- 
tation. 

Fractures  of  the  metatarsal  bones  are  due  to  direct 
force  and  are  almost  always  compound.  Fractures  from 
crushes  usually  demand  excision  or  amputation.  When 
only  one  bone  is  broken  displacement  is  slight,  there  is 
severe  pain  on  motion  and  pressure,  and  crepitus  can  gener- 
ally be  obtained.  A  simple  fracture  of  a  metatarsal  bone 
is  dressed  in  a  fracture-box  for  one  week  and  in  immovable 
dressings  for  three  weeks. 

Fractures  of  the  phalanges  of  the  toes  are  due  to  direct 
force  and  are  often  compound.  They  may  require  imme- 
diate amputation. 

Treatment. — In  a  compound  fracture  where  amputation  is 
unnecessary,  drain  with  strands  of  catgut  for  forty-eight 
hours  and  dress  antiseptically ;  at  the  end  of  this  time  apply 
over  the  bichloride  gauze  a  gutta-percha  or  a  pasteboard 
splint  extending  from  beyond  the  end  of  the  toe  to  well  up 
upon  the  sole  of  the  foot,  and  fix  the  splint  in  place  with  a 
spiral  bandage  of  the  toe  and  instep.  The  splint  is  to  be 
worn  for  four  weeks.  In  a  simple  fracture,  use  a  splint 
of  gutta-percha,  pasteboard,  or  binder's  board,  and  let  it 
be  worn  for  three  weeks. 

3.  Diseases  of  the  Joints. 

Synovitis  is  an  inflammation  of  the  synovial  membrane 
alone.  If  other  structures  besides  the  synovial  membrane 
are  involved,  the  condition  is  known  as  "  arthritis."  Most 
cases  of  acute  joint-inflammation  begin  as  synovitis.  Two 
forms   of  synovitis   exist — namely,   acute  and  clwouic. 

Acute  Synovitis. — The  causes  of  acute  synovitis  are  con- 
tusions, sprains,  twists,  exposure  to  cold  or  damp,  wounds, 


396  A   MANUAL    OF  SURGERY. 

infection,  and  rheumatism.  The  membrane  is  red  and 
swollen  and  the  joint  contains  an  excess  of  turbid  fibrinous 
fluid.  If  the  inflammation  advances,  arthritis  arises  and 
sometimes  blood  is  effused. 

Sy}iiptoi}is. — The  symptoms  of  acute  synovitis  are — pain, 
which  is  increased  by  motion  of  the  joint,  by  pressure  upon 
the  articulation,  and  by  a  dependent  position  of  the  limb, 
and  which  is  worse  at  night ;  a  fluctuating  swelling  is  noted, 
most  marked  between  the  ligaments,  which  swelling  bulges 
out  the  synovial  area  and  hides  or  obscures  the  articular 
heads  of  the  bones  (the  patella  floats  up  above  the  condyles)  ; 
the  skin  over  the  joint  is  not  reddened,  but  feels  hot  to  the 
hand  of  the  observer ;  the  joint  is  partly  flexed  ;  fever  exists, 
varying  in  degree  with  the  size  of  the  joint,  the  acuteness  of 
the  attack,  and  the  nature  of  the  cause.  In  septic  cases 
rigors  occur,  there  is  a  septic  temperature,  and  the  joint 
soon  gives  evidence  of  containing  pus  (periarticular  oedema). 
Traumatic  synovitis  without  infection  tends  toward  cure  with- 
out suppuration  if  the  patient  is  healthy,  and  ankylosis  is  rare. 
Rheumatic  synovitis  proceeds  to  arthritis. 

Treatment. — In  treating  acute  synovitis,  immobilize  the 
joint  in  the  position  of  rest  (semiflexion),  apply  leeches, 
use  the  ice-bag"  or  the  Leiter  coil,  and  follow  the  cold  by 
lead-water  and  laudanum.  After  a  day  or  two  apply  gentle 
pressure,  intermittent  heat,  and  iodine  and  ichthyol.  If  the 
effusion  is  very  great  and  persistent,  and  pressure,  astringents, 
and  sorbefacients  fail,  aspirate  with  antiseptic  care.  If  effu- 
sion recurs,  apply  a  plaster-of  Paris  dressing  or  use  flying 
blisters  and  massage. 

Chronic  Synovitis. — Chronic  synovitis  follows  acute 
synovitis  or  it  may  be  chronic  from  the  start.  The  syno- 
vial membrane  looks  nearly  natural,  but  is  oedematous, 
and  the  joint  contains  an  excess  of  fluid.  If  the  quantity 
of  fluid  is  large,  the  patella  floats  up  and  the  disease  is  called 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      397 

"  hydrops  articuli  "  or  "  dropsy."  In  prolonged  cases  the 
synovial  membrane  is  thickened  in  some  places,  softened  in 
others,  and  is  often  adherent,  and  the  villous  processes  of 
the  synovial  membrane  are  hypertrophied.  If  the  membrane 
becomes  extensively  softened  (pulpy  degeneration),  the  soft- 
ened areas  bulge  and  suppuration  eventually  occurs. 

Symptoms. — In  chronic  synovitis  pain  is  absent  or  is  only 
present  through  exercise  or  from  pressure,  and  is  slight  even 
then ;  there  is  some  limitation  of  movement ;  passive  motion 
may  develop  creaking  or  crepitus ;  fluctuation  is  apparent ; 
there  is  atrophy  in  the  muscles  about  the  joint;  and  the 
hypodermatic  needle  will  draw  out  a  viscid,  straw-colored 
or  bloody  fluid. 

Treatment. — For  hydrops  use  rest  and  pressure  (a  Martin 
rubber  bandage  or,  better,  a  plaster  dressing),  massage, 
douches,  frictions,  passive  movements,  and  flying  blisters. 
Painting  the  joint  with  iodine  and  spreading  over  it  blue 
ointment,  and  inunctions  with  ichthyol,  may  do  good.  The 
actual  cautery  is  a  valuable  expedient.  Aspiration  and 
the  subsequent  use  of  a  plaster-of-Paris  bandage  may  be 
tried  in  some  cases.  Many  surgeons  advise  aspiration,  wash- 
ing out  with  boiled  water,  injecting  a  5  per  cent,  solution  of 
carbolic  acid,  and  immobilizing.  Incision  and  drainage  is 
a  radical  but  proper  plan.  If  pulpy  degeneration  exists, 
perform  an  excision  or  an  erasion.  If  pus  forms,  incise  at 
once  and  drain.  Internally,  treat  any  existing  diathesis  and 
give  good  food,  tonics,  and  stimulants. 

Arthritis, — By  this  term  is  meant  not  only  inflammation 
of  a  synovial  membrane,  but  also  of  other  structures  com- 
posing and  surrounding  a  joint.  It  may  follow  a  traumatic 
synovitis ;  it  may  be  due  to  pus  cocci,  to  tubercle  bacilli,  to 
infectious  diseases  (gonorrhoea  and  typhoid  fever),  to  rheu- 
matism, to  gout,  to  syphilis,  and  to  lesions  of  the  spinal  cord. 
Arthritis  may  be  either  acute  or  chronic. 


398  A    MANUAL    OF  SURGERY. 

Tubercular  Arthritis  (White  swclHng;  Strumous  joint; 
Pulpy  degeneration). — Pathology  and  Symptoms. — The  ex- 
citing cause  of  tubercular  arthritis  may  be  strains,  blows, 
twists,  or  cold.  The  primary  infection  with  tubercle  bacilli 
is  usually  in  the  bone,  though  it  may  be  in  the  synovial 
membrane,  the  joint-capsule,  or  the  structures  about  the 
joint.  If  the  primary  infective  focus  is  in  the  bone,  a 
portion  of  the  cartilage  is  destroyed  and  the  joint  is  opened, 
or  a  sinus  forms  and  perforates  the  synovial  membrane. 
When  tubercular  inflammation  attacks  the  synovial  mem- 
brane granulation  tissue  is  formed,  and  the  capsule  and 
periarticular  structures  soon  become  involved  in  the  process; 
the  parts  thicken  and  soften  from  caseation,  and  they  may  be 
covered  with  tubercles,  though  but  little  fluid  is  usually 
effused  into  the  joint.  Some  few  cases  present  large  joint- 
effusions.  In  the  ordinary  form  of  arthritis  there  occurs 
what  is  known  as  "  gelatiniform  degeneration;"  the  embry- 
onic tissue  is  formed  in  large  amount  as  fungous  growths ; 
the  structures  are  markedly  oedematous  and  softened  ;  the 
relaxed  ligaments  yield  under  pressure ;  the  natural  contour 
of  the  joint  is  lost,  and  it  becomes  spindle-shaped  ;  all  the 
structures,  articular  and  periarticular,  are  glued  into  one 
mass ;  the  skin  about  the  joint  is  white,  thick,  and  adherent, 
and  in  it  one  or  more  large  veins  are  seen ;  fluctuation  or 
pseudo-fluctuation  is  noted  when  caseation  has  occurred  ; 
pain  is  not  often  severe,  but  it  can  usually  be  elicited  by 
certain  motions  or  by  firm  pressure  (but  the  pain  will  always 
be  severe  when  the  epiphysis  is  involved) ;  the  temperature 
of  the  part  is  somewhat  elevated;  deformity  results  from 
destruction  of  bone,  cartilage,  and  ligament,  from  muscular 
spasms,  and  from  the  habitual  assumption  of  certain  attitudes 
to  secure  relief  from  pain;  there  is  soon  impairment  of  joint- 
motions.  When  the  products  of  a  tubercular  arthritis  caseate, 
the  thick  liquid  seeks  exit  by  forming  sinuses  from  which 


DISEASES  AND   IXJURIES   OE  BOXES  AXD  JOIXTS.      399 

caseous  pus  runs.  If  a  sinus  becomes  infected  with  pyo- 
genic cocci,  and  the  joint  itself  becomes  their  prey,  acute 
suppuration  arises  in  the  joint,  and  constitutional  involvement 
is  pronounced  and  perilous  to  life. 

In  pannous  synovitis  a  large  effusion  is  formed,  there  is 
but  little  granulation  tissue,  though  the  tubercles  are  present 
in  large  numbers,  and  the  ligaments  and  structures  about  the 
joint  are  slightly  or  not  at  all  implicated.  The  diagnosis 
early  in  a  case  is  difficult,  often  impossible,  and  the  prognosis 
is  grave.  In  only  a  very  few  cases,  even  when  recognized 
early,  is  a  cure  obtained  without  impairment  of  joint-function. 
The  best  that  can  usuall)'  be  accomplished  is  a  cure  with 
more  or  less  ankylosis,  fibrous  or  bony ;  but  often  ankylosis 
is  complete.  Long  after  the  disease  is  apparently  cured,  it 
may  break  forth  anew.  Tubercular  lesions  may  arise  in  a 
distant  organ,  or  general  tuberculosis  may  occur.  Caseation 
is  apt  to  produce  severe  constitutional  disorder.  Infection 
by  pus  organisms  gives  rise  to  grave  danger  of  septicaemia. 
Death  is  not  unusual  from  exhaustion,  from  septicaemia, 
from  disseminated  tuberculosis,  from  tubercle  in  an  import- 
ant organ,  or  from  amyloid  disease. 

TreatJHcnt. — Constitutionally,  the  treatment  is  directed 
against  the  tubercular  diathesis.  Locally,  rest  is  of  the 
first  importance,  and  it  is  maintained  for  many  weeks,  it  being 
obtained  by  splints,  by  a  plaster-of-Paris  bandage,  or  by 
extension  appliances.  Aspiration  can  be  used  for  fluid 
accumulations.  Caseous  masses  are  often  let  alone,  or  an 
aspirator  is  used  and  the  joint  drained,  washed  out  with 
boiled  water,  and  injected  with  an  emulsion  of  iodoform  and 
glycerin  (10  per  cent.).  Injections  of  balsam  of  Peru  or  of 
iodoform  emulsion  about  the  joint  once  a  week  are  efficient 
in  some  cases.  If  these  means  fail,  if  the  patient  gets  worse, 
or  if  the  condition  of  the  sufferer  renders  dangerous  the  pro- 
longed   conservative    course,   then    operate,    removing    the 


400  A   MANUAL    OF  SURGERY. 

entire  diseased  area  by  erasion,  by  excision,  or  by  ampu- 
tation. Always  remember  that  an  incomplete  operation,  a 
partial  removal,  is  worse  than  no  operation,  as  it  opens  the 
portals  to  systemic  infection,  and  may  be  responsible  for  a 
general  tuberculosis,  septicaemia,  or  pyaemia. 

Tuberculosis  of  Special  Joints. — Tuberculosis  of  the 
hip-joint  (hip  disease;  morbus  coxarius;  morbus  coxae; 
hip-joint  disease)  usually  begins  in  the  epiphysis.  It  is  com- 
monest in  children,  but  it  may  arise  in  adults.  Traumatism 
and  cold  may  be  exciting  causes. 

Syniptoitis. — In  tuberculosis  of  the  hip-joint  there  are 
three  stages:  (i)  the  stage  of  microbic  deposition  and 
multiplication,  the  products  of  the  bacilli  causing  irritation 
and  new  growth ;  (2)  the  stage  of  progression,  with  forma- 
tion of  embryonic-tissue  masses  and  effusion  into  the  joint; 
and  (3)  the  stage  of  caseation,  with  destruction  of  the  joint 
and  often  of  the  structures  about  it. 

The  symptoms  of  the  first  stage  are  slight  and  may 
be  overlooked  entirely.  In  a  child  there  are  night-terrors; 
on  getting  about  in  the  morning  the  child  shows  some 
lameness,  which  wears  off  during  the  day,  and  it  soon  grows 
tired  while  playing  and  lies  down  to  rest.  There  may  be 
a  slight  limp  ;  a  slight  adductor  spasm  may  often  be  noted ; 
some  pain  may  occur  in  the  hip  on  tapping  the  sole  of  the 
foot  while  the  patient  is  recumbent  with  the  leg  extended ; 
pain  may  be  complained  of  at  night  in  the  hip,  in  the  front 
of  the  thigh,  or  at  the  inside  of  the  knee.  The  diagnosis  in 
this  stage  is  more  or  less  problematical. 

In  the  second  stage,  or  the  stage  of  apparent  lengthening, 
the  symptoms  are  positive.  The  child  limps  ;  the  adductor 
muscles  are  rigid ;  the  hip  is  broadened  by  an  effusion  in 
the  joint,  and  fluctuation  may  possibly  be  detected ;  the 
thigh-muscles  are  atrophied ;  the  extremity  is  pushed  for- 
ward, abducted,  and  everted  (the  patient  tilts  the  pelvis  so  as 


HIP-JOINT    DISEASE. 


Plate  9, 


I,  2.  Effects  on  the  Lumbar  Spine  of  Flexing  and  Extending  the  Diseased  Leg  in  Hip  Disease 
(Albert).  3,4.  Positions  in  Coxalgia  (Albert).  5.  Strap-and-slipper 'Apparatus  for  Fracture  of  Pos- 
terior Portion  of  the  Calcaneum  (after  Hamilton).  6.  Extension  in  Hip  Disease  (Treves).  7.  Exten- 
sion of  the  Limb  in  a  Flexed  and  Adducted  Position  (Treves).  8.  Extension  of  the  Limb  in  a  Flexed 
and  Abducted  Joint  (Treves). 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      40I 

to  rest  his  weight  on  the  sound  Hmb) ;  the  thigh  is  some- 
what flexed;  in  very  rare  instances  adduction  is  present; 
pain  exists,  often  sudden  or  starting,  and  is  located  in  the 
joint,  on  the  front  of  the  thigh,  and  to  the  inner  side  of  the 
knee  in  the  course  of  the  obturator  nerve;  the  pain  is 
aggravated  at  night ;  and  full  extension  and  complete  abduc- 
tion are  not  possible.  The  gluteal  muscles  waste,  and  the 
gluteal  crease  is  on  a  lower  level  than  is  that  of  the  sound 
side.  Jarring  of  the  heel  when  the  extremity  is  in  extension 
causes  pain  in  the  hip.  The  above  symptoms  arise  chiefly 
from  joint-effusion,  reflex  irritation,  and  involuntary  or  spas- 
modic muscular  contractions.  Lengthening  in  the  second 
stage  is  apparent,  not  real,  but  this  stage  is  spoken  of  as  the 
'*  stage  of  lengthening."  The  position  is  shown  on  Plate  9 
(Fig.  4).  The  fluid  effusion  may  be  absorbed  or  may  find 
its  way  externally  by  means  of  sinuses.  The  latter  condi- 
tion is  known  as  "  abscess  of  the  hip."  The  absorption  of 
the  exudate  or  the  rupture  of  the  capsule  permits  the  con- 
tracting muscles  to  bring  the  head  of  the  femur  into  firm 
contact  with  the  acetabulum  or  its  brim  ;  the  bones  are 
worn  away  and  destroyed,  shortening  results,  abduction  and 
flexion  are  increased,  and  the  third  stage  is  established. 

In  the  tlnrd  stage  the  head  of  the  femur  goes  upward  and 
outward  upon  the  rim  of  the  acetabulum,  the  thigh  is  flexed 
and  fixed,  and  attempts  at  extension  when  the  patient  is 
recumbent  cause  the  pelvis  to  tilt  forward  and  occasion  a 
marked  lumbar  curve  (PL  9,  Fig.  3),  which  is  due  to  the 
pelvis  moving  with  the  femur  as  if  ankylosed,  and  which 
disappears  on  flexion.  In  the  third  stage  adduction  occurs 
because  of  the  ascent  and  movement  outward  of  the  head 
of  the  bone.  Shortening  is  marked.  After  a  hip-abscess 
finds  an  external  outlet  pyogenic  infection  is  very  apt  to 
take  place  and  inflammation  is  liable  to  arise,  followed  by 
that  state  which  is  designated  as  "  hectic."     If  a  cure  follows 

26 


402 


A   MANUAL    OF  SURGERY. 


the  third  stage,  partial  or  complete  ankylosis  takes  place; 
if  death  ensues,  it  may  be  due  to  septicaemia,  tuberculosis  of 
the  viscera,  exhaustion,  or  amyloid  degeneration. 

Diagnosis  is  very  easy  in  well-established  cases  of  hip  dis- 
ease, but  very  difficult  when  the  disease  is  incipient.  Always 
make  a  systematic  and  thorough  examination.  Undress  the 
patient  and  place  him  recumbent  upon  a  table  or  a  hard 
mattress,  with  the  legs  extended,  and  note  if  the  heels  are 
level  and  if  the  iliac  spines  are  on  the  same  level  (depressed 
spine  on  the  affected  side  means  abducted  extremity,  the 
degree  of  which  is  determined  by  carrying  the  limb  out  until 
the  spines  are  horizontal ;  elevation  of  the  iliac  spine  on  the 
affected  side  means  adduction,  the  amount  of  which  is  deter- 


FiG.  60. — Positions  in  Hip-joint  Disease  (after  the  plan  of  Howard  Marsh  and  Treves). 
A. — e  f,  lumbar  spine  :  b  d,  limb  fixed  in  flexion  and  abduction — useless  for  walking,  b. — e  /, 
lumbar  spine.  Patient  corrects  the  condition  in  Figure  a  by  curving  the  lumbar  spine  for- 
ward and  rotating  the  pelvis  on  its  transverse  axis,  thus  making  the  femur  point  downward. 
The  lumbar  spine  is  curved  laterally,  the  pelvis  ascending  on  the  sound  side  and  descending 
on  the  affected  side  ('apparent  lengthening).  C. — b  d,  limb  fixed  in  flexion  and  adduction. 
D. — e  f,  curve  of  lumbar  spine  to  correct  condition  in  Figure  c  (apparent  shortening). 

mined  by  adducting  the  limb  until  the  spines  are  horizontal ; 
Fig.  60);  try  all  the  movements  belonging  to  the  joint,  to 
detect  any  limitations  ;  try  if  bringing  down  the  knee  pro- 
duces lordosis  (PI.  9,  Figs.  I,  2);  look  for  swelling  and  for 
muscular  wasting ;  feel  if  the  head  of  the  bone  is  enlarged ; 
observe  if  motion  produces  pain  or  if  pressure  causes  tender- 
ness ;  and  always  carefully  elicit  the  history  of  the  attack,  of 
the  person,  and  of  the  family. 


DISEASES  AND   INJURIES    OF  BONES  AND  JOINTS.      403 

Hip  disease  may  be  confounded  with  spinal  caries  in  which 
a  psoas  or  a  lumbar  abscess  has  formed,  with  sacro-iliac 
disease,  with  infantile  paralysis,  with  congenital  dislocation, 
with  lordosis  from  rickets,  and  with  gluteal  abscess.  In  hip 
disease  there  is  always  some  lameness  ;  pain  may  be  severe 
or  may  be  absent  entirely,  and  may  be  in  the  hip  or  be  referred 
to  the  front  of  the  thigh  or  to  the  inner  side  of  the  knee. 
Always  remember  that  the  pain  is  not  characteristic,  and  that 
pain  in  the  same  localities  may  arise  from  aneurysm  of  the 
femoral  or  iliac  arteries,  from  abscess  in  Scarpa's  triangle, 
from,  caries  of  the  lumbar  vertebrae,  from  sacro-iliac  disease, 
and  from  cancer  of  the  rectum.  Altered  position  of  the  limb, 
limitation  of  movement  in  the  hip-joint,  muscular  wasting, 
and  swelling  soon  arise  in  hip-joint  disease. 

In  disease  of  the  sacro-iliac  joint,  examination  shows  that 
the  movements  of  the  hip-joint  are  unlimited  and  produce 
no  pain,  and  that  pain  is  developed  by  pressure  over  the 
sacro-iliac  articulation  and  by  pressing  the  ilia  together. 
In  infantile  paralysis  there  is  no  pain,  but  paralysis  with 
great  muscular  atrophy,  which  comes  on  with  considerable 
rapidity.  In  spinal  caries  with  psoas  abscess  the  evidences 
of  disease  of  the  vertebrae  are  clear  and  the  pus  is  located 
in  the  groin  external  to  the  femoral  vessels.  The  pus  of 
hip-abscess  generally  gathers  under  the  tensor  vaginae 
femoris  muscle,  but  it  may  reach  Scarpa's  triangle  by  pass- 
ing through  the  cotyloid  notch  or  through  the  bursa  under 
the  psoas  muscle ;  it  may  appear  under  the  glutei.  Matter 
from  a  caseating  acetabulum  may  reach  the  inside  of  the 
pelvis  and  appear  above  Poupart's  ligament. 

Prognosis. — If  the  case  of  hip  disease  is  seen  early,  the 
chances  of  cure  are  excellent  in  children,  in  whom  the  dis- 
ease may  be  arrested  at  any  stage.  The  longer  the  duration 
of  the  disease  and  the  older  the  subject,  the  more  unfavor- 
able is  the  prognosis.     The  cure  takes  many  months,  and 


404  A    MANUAL    OF  SURGERY. 

advanced  cases  only  get  well  by  means  of  ankylosis  with 
shortening  and  deformity.     Hip  disease  may  recur  years  after 
apparent  cure,  and  a  per^n  who  has  had  hip  disease  runs 
•a  strong  chance  of  developing  visceral  tuberculosis. 

Complications. — The  complications  that  may  accompany 
hip  disease  are  the  following:  Abscess,  as  above  noted. 
Tuberculous  meningitis^  or  the  condition  known  as  "  acute 
hydrocephalus,"  or  water  on  the  brain,  may  arise  during  the 
progress  of  the  case  or  after  apparent  cure,  and  is  apt  to  ensue 
upon  incomplete  operations.  It  is  almost  inevitably  fatal. 
Amyloid,  lardaceous,  or  waxy  degenei'ation  of  viscera,  which 
condition  follows  upon  profuse  and  long-continued  suppura- 
tions, and  which  is  apt  to  arise  in  the  liver,  spleen,  kidneys, 
or  intestinal  mucous  membrane.  Tuberculosis  is  not  the  only 
cause,  syphilis  being  responsible  for  at  least  thirty  per  cent, 
of  all  cases.  In  amyloid  disease  of  the  liver  this  organ  is 
much  enlarged,  smooth,  painless,  and  of  increased  consist- 
ency, there  is  no  jaundice,  the  spleen  is  apt  to  be  enlarged, 
and  albuminuria  is  the  rule.  In  amyloid  kidney  large 
amounts  of  pale  urine  of  low  specific  gravity  are  voided ; 
albumin  is  usually  present  in  large  amount,  but  may  be 
absent ;  globulin  may  often  be  found,  as  may  also  hyaline, 
fatty,  or  granular  casts  ;  the  patient  is  anaemic,  and  dropsy 
usually  exists.  Test  the  hyaline  casts  with  iodine  for  amyl- 
oid material.  Amyloid  changes  are  usually  slow  in  onset, 
but  they  may  be  rapid ;  they  are  commoner  in  men  than  in 
women,  and  are  most  frequently  encountered  in  individuals 
between  the  ages  of  ten  and  thirty.  Slight  amyloid  change 
may  be  recovered  from,  but  an  extensive  degeneration  brings 
about  a  fatal  result.  Dr.  Dickson's  famous  theory  of  how 
this  tissue-change  is  caused  is  that  the  flow  of  pus  drains  off 
from  the  body  the  alkaline  salts,  especially  the  salts  of 
potassium,  which  drainage  results  in  visceral  depositions 
of  de-alkalinized  fibrin.    Phthisis  pulmonalis  is  a  rare  compli- 


DISEASES  AND   INJURIES   OE  BONES  AND  JOINTS.      405 

cation,  but  is  a  common  sequence,  often  arising,  sooner  or 
later,  after  the  hip  disease  is  cured. 

Treatment. — In  the  early  stage  of  hip  disease  the  treat- 
ment consists  of  rest.  Place  the  patient  upon  a  sohd  mat- 
tress and  apply  extension.  In  children  under  ten  years  of 
age,  use  a  weight  of  from  three  to  five  pounds  ;  in  children 
between  ten  and  twenty,  use  a  weight  of  from  five  to  eight 
pounds.  A  long  splint  is  often  applied  to  the  sound  side  to 
keep  the  patient  recumbent  and  horizontal.  Apply  the  exten- 
sion in  the  long  axis  of  the  limb,  the  extremity  being  placed  in 
the  line  of  the  deformity  due  to  disease  and  being  supported 
by  pillows.  In  lordosis  from  thigh-flexion,  raise  the  limb 
until  the  iliac  spine  is  straight  (PL  9,  Fig.  6).  If  the  spine  is 
depressed  on  the  affected  side,  abduct  the  limb  (PL  9,  Fig.  7); 
if  the  spine  is  elevated,  adduct  the  limb  until  the  spines  are 
horizontal  (PL  9,  Fig.  8).  The  object  in  taking  these  precau- 
tions is  to  enable  the  extension  to  separate  the  femoral  head 
and  the  acetabulum.  Extension  will  remove  flexion  in  two 
weeks  in  a  recent  case  and  in  the  course  of  some  months  in 
an  older  case.  As  flexion  is  relieved  remove  the  pillows  and 
lower  the  leg  so  as  to  keep  up  extension  in  the  long  axis 
of  the  thigh.  Abduction  and  adduction  cannot  be  removed 
by  extension.  Always  use  a  cradle  to  hold  up  the  bed- 
clothing. 

Abduction  demands  no  special  treatment.  In  a  movable 
joint  it  will  disappear,  and  in  an  ankylosed  joint  it  is  an  ad- 
vantage, compensating  by  apparent  lengthening  for  the  short- 
ening due  to  bone-absorption  or  to  stunted  growth  of  the  limb. 
Adduction  requires  an  addition  of  several  pounds  to  the  ex- 
tension weight,  the  use  of  a  long  splint  on  the  sound  limb,  and 
the  drawing  up  of  the  sound  limb  by  a  rope  and  pulley  toward 
the  head  of  the  bed.  The  weight  used  to  pull  the  sound  side 
toward  the  head  of  the  bed  is  equal  to  that  used  to  pull  the 
damaged  side  to  the  foot  of  the  bed.      This  expedient  is 


4o6 


A   MANUAL    OF  SURGERY. 


used  for  a  month  or  six  weeks.  In  old  cases  where  the 
weight  will  not  bring  about  extension,  anaesthetize  the 
patient,  gently  straighten  the  limb  a  very  little,  and  re- 
apply the  weight.  Thomas's  splint  is  used  by  many,  and 
it    may  be  combined  with  weight    extension  (Fig.  6i);    or 

Sayre's  splint  (Fig.  62)  may  be  em- 
ployed. Wyeth's  apparatus  (Fig.  63) 
is    a    favorite    with    miany    American 


Extension  in  a  mild  case  must  be 
continued  for  three  months  after  the 
symptoms  have  disappeared,  and  in  a 
severe  case  the  period  must  be  six 
months.  The  weight  is  gradually 
taken    off;    if    symptoms    recur,    the 


weight 


is  reapplied ;  if  they  do  not 
recur,  apply  a  traction  splint  or  a 
plaster  dressing,  put  a  high-heeled  boot 
on  the  sound  limb,  and  send  the  patient 
out  on  crutches.  In  young  children 
Fig.  61.— Thomas's  Posterior  cxtcnsion  cau  bc  made  in  a  wheeled 
Splint  (Tiemann).  Carriage,  thus  enabling  the  patient  to 

go  out  in  the  fresh  air  and   sunlight.     The    general   treat- 
ment is  tonic  and  restorative. 

If  an  abscess  forms,  incise  it  with  the  most  thorough  anti- 
septic care,  let  the  fluid  drain  away,  wash  out  with  corrosive- 
sublimate  solution  and  then  with  boiled  water,  inject  with 
iodoform  emulsion,  insert  a  tube,  and  dress  antiseptically. 
The  old  plan  of  not  operating  until  rupture  was  seen  to  be 
inevitable  was  bad.  To  open  early  and  antiseptically  often 
means  rapid  healing,  the  prevention  of  burrowing,  a  lessened 
danger  of  visceral  infection,  and  an  earlier  cure.  Hectic  will 
not  arise  if  the  abscess  is  opened  with  antiseptic  care. 

Excision  of  the  hip  is  to  be  performed  when  the  head  of 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      4O7 


the  femur  is  detached  and  lies  loose  in  the  joint ;  when  pro- 
fuse suppuration  continues  for  a  long  time,  and  other  methods 
fail  to  arrest  it ;  when  amyloid  disease  is  beginning ;  or  when 
very  faulty  position  is  inevitable  without  operation.  Excision 
is  an  operation  of  considerable  danger,  and  the  older  the 
person  the  greater  the  danger.     When  there    is    extensive 


Fig.  62.— Sayre's  Long  Splint.  Fig.  63.— Wyeth's  Combination  Method. 

disease  of  the  femur,  when  excision  has  been  tried  and  has 
failed,  and  when  the  patient  has  not  the  recuperative  power 
to  stand  the  long  siege  following  excision,  amputate.^ 

Knee-joint  Disease  (White  swelling). — After  the  hip,  the 
knee  is,  of  all  joints,  the  commonest  site  for  tuberculous  dis- 
ease.    Knee-joint  disease  begins  as  a  synovitis,  or  oftener  as 
1  See  the  admirable  article  of  Howard  Marsh  in  Treves's  Manual. 


4o8 


A    MANUAL    OF  SUKGEKY. 


V"? 


an  inflammation  of  the  femoral  or  the  tibial  epiphysis.  If  an 
acute  synovitis  ushers  in  the  case,  there  may  be  large  effusion 
into  the  knee-joint  and  partial  flexion.  Swelling  is  usually 
slight  in  knee-joint  disease.  Pulpy  degeneration  of  the 
synovial  membrane  occurs ;  the  joint  enlarges ;  the  liga- 
ments soften ;  the  skin  is  cedematous ;  muscular  spasm  is 
marked ;  the  leg  is  flexed ;  the  bones  are  displaced  back- 
ward and  outward,  the  foot  being  everted ;  lameness  exists,  due 
chiefly  to  deformity;  pain  may  be  absent,  is  often  slight,  and 

is  rarely  severe.  When  the 
disease  begins  in  the  bone 
or  an  epiphysis  there  are 
pain,  tenderness,  lameness, 
swelling,  inability  to  ex- 
tend the  limb  completely, 
sudden  spasmodic  muscu- 
lar contractions,  and  final 
involvement  of  the  joint. 
When  an  abscess  forms,  it 
may  destroy  the  joint  very 
rapidly  or  it  may  break  ex- 
ternally. 
^^^  Treatment. — In    treating 

Fig.     64.-Sayre's       Fig.  65.-Hutchinson's    kneC-joint     discaSC,    COiploy 
Knee-splint  Applied.     Knee-joint  Splint. 

general  antitubercular  treat- 
ment. Apply  splints  (Figs.  64,  65),  extension  (Fig.  66), 
or  a  plaster-of-Paris  bandage,  and  keep  the  patient  in 
bed  for  a  few  weeks ;  then  permit  him  to  go  out  with 
crutches,  with  a  high-heeled  shoe  upon  the  sound  foot. 
In  cases  in  which  treatment  was  begun  early  the  disease 
can  often  be  arrested  in  from  eight  to  twelve  months. 
If  the  symptoms  do  not  abate  after  a  number  of  weeks, 
or  if  the  condition  grows  worse  and  an  abscess  arises, 
aspirate  and  inject  iodoform  emulsion.     If  these  means  fail, 


DISEASES  AND   INJURIES    OF  BONES  AND  JOINTS.      409 

open  the  joint  and  perform  an  excision  or  an  erasion.  Some 
cases  demand  amputation,  which,  if  the  patient's  health  is 
much  impaired,  is  to  be  preferred  to  excision. 

Ankle-joint  disease  begins  usually  as  a  chronic  synovitis, 
but  it  may  arise  in  the  tibial  epiphysis.     The  symptoms  are 


Fig.  66. — Sayre's  Double  Extension  of  the  Knee-joint  (Tiemann). 

pain,  swelling,  lameness,  limitation  of  joint-movements,  and 
atrophy  of  the  calf-muscles.  Suppuration  often  occurs,  and 
sinuses  form. 

Treatment. — The  treatment  of  ankle-joint  disease  consists 
in  the  employment  of  antitubercular  remedies,  and  of  rest  by 
means  of  splints  or  plaster.  Caution  the  patient  to  avoid 
standing  upon  the  diseased  extremity.  When  suppuration 
occurs,  open,  drain,  wash  out  with  corrosive-sublimate  solu- 
tion and  with  iodoform  emulsion,  and  put  up  the  ankle-joint 
in  plaster.  When  joint-disorganization  occurs,  perform  an 
excision  or  an  erasion.  Some  cases  demand  amputation 
(Syme's  amputation  being  preferred  by  some,  amputation 
above  the  ankle  being  approved  by  many).  Osteoplastic 
resection  is  sometimes  advised  (Wladimiroff-Mikulicz  opera- 
tion). 

Shoulder-joint  disease,  which  is  rare  in  children  and  is 
commonest  in  adults,  begins  either  in  the  synovial  mem- 
brane or   in   the  epiphysis.     Pain   is   slight,   atrophy  of  the 


4IO  A    MANUAL    OF  SURGEKY. 

deltoid  and  other  muscles  is  noted,  the  joint  is  stiff,  and  the 
scapula  follows  the  motions  of  the  humerus.  Suppuration  is 
rare. 

Treatment. — In  treating  shoulder-joint  disease,  employ 
antitubercular  remedies  and  iodoform  ointment.  Put  on  a 
shoulder-cap,  apply  the  second  roller  of  Desault,  and  hang 
the  hand  in  a  slincr.  Maintain  rest  for  at  least  four  months. 
If  an  abscess  forms,  open  and  drain  it.  In  rare  instances 
dead  bone  will  have  to  be  gouged  away.  Caries  sicca  may 
occur.     Excision  is  sometimes  required. 

Elbow-joint  disease  may  begin  in  the  humerus  or  the 
ulna.  The  joint  is  swollen,  its  movements  are  somewhat 
limited,  the  skin  is  usually  hot,  muscular  wasting  is  pro- 
nounced, and  pain  is  generally  slight.     Pus  may  form. 

Treatmcfit. — In  treating  elbow-joint  disease,  employ  anti- 
tubercular  foods,  drugs,  and  hygienic  measures  ;  iodoform 
ointment  locally;  rest  by  means  of  an  anterior  angular  splint 
(Fig.  6'j)  and  a  triangular  sling.     If  matter  forms,  open  the 


Fig.  67. — Stromeyer's  Anterior  Angular  Splint. 

joint  and  drain.  Splints  are  to  be  worn  for  from  four  months 
to  a  year.  If  any  considerable  area  becomes  carious,  perform 
an  erasion  or  an  excision. 

Wrist-joint  disease  may  arise  at  any  age.  The  joint 
presents  a  puffy  swelling,  loses  its  normal  contour,  and 
becomes  spindle-shaped.  Hand-movements  are  impaired, 
pronation  and  supination  cannot  completely  or  satisfactorily 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      41  I 

be  performed,  the  joint  is  stiff  and  partly  flexed,  the  grasp  is 
enfeebled,  pain  may  be  severe  or  slight,  the  skin  is  usually 
hot,  and  muscular  atrophy  is  marked. 

Treatment. — The  essential  treatment  in  wrist-joint  disease 
comprises  cod-liver  oil,  tonics,  good  food  and  fresh  air,  and 
iodoform  ointment  locally.  Apply  a  Bond  splint  and  sling 
or  put  on  a  plaster  bandage,  and  maintain  rigid  rest  for  from 
four. to  six  months.  Suppuration  demands  incision  and 
drainage  with  the  maintenance  of  rest  A  moderate  amount 
of  caries  is  treated  by  drainage  and  rest.  Necrosis  demands 
removal  of  the  sequestra.     Extensive  caries  requires  excision. 

Septic  Arthritis. — This  infection  is  usually  due  to  the 
staphylococcus  pyogenes  aureus  or  to  the  streptococcus 
pyogenes  which  find  entrance  by  means  of  a  wound,  by  the 
spontaneous  evacuation  into  a  joint  of  the  products  of  an 
osteomyelitis,  by  extension  of  suppurative  inflammation 
through  contiguous  structures,  or  by  the  blood-stream,  as 
in  pyaemia  and  other  conditions. 

Symptoms. — The  symptoms  of  septic  arthritis  are — severe 
pain,  which  is  aggravated  by  motion  and  is  worse  at  night; 
discoloration,  heat,  and  oedema  of  the  skin ;  partial  flexion 
of  the  joint ;  fluctuation ;  and  marked  constitutional  symp- 
toms of  sepsis.  The  joint  tends  to  rapid  disorganization, 
and  fatal  septicaemia  is  very  apt  to  occur.  In  pyasmic  arthri- 
tis several  joints  become  infected. 

Treatment. — The  treatment  in  septic  arthritis  consists  in 
prompt  incision,  evacuation,  antiseptic  irrigation,  drainage, 
antiseptic  dressing,  and  immobilization.  Cure  is  followed, 
as  a  rule,  by  ankylosis,  but  in  cases  treated  early  the  joint 
may  be  preserved. 

Infective  arthritis  arises  in  the  course  of  an  acute  infec- 
tious disease  (such  as  erysipelas,  typhoid  fever,  measles, 
scarlatina,  variola),  and  may  be  due  to  pyogenic  cocci  or  to 
the  specific  micro-organism  of  the  acute  infectious  disease. 


412  A    MANUAL    OF  SURGERY. 

Joint-inflammation  arising  in  the  course,  or  as  a  sequel,  of 
an  acute  infectious  disease  may  or  may  not  suppurate. 

Symptoms  and  Treatment. — If  no  suppuration  takes  place, 
the  symptoms  of  the  attack  resemble  those  of  rheumatism ; 
if  suppuration  occurs,  the  symptoms  are  identical  with  those 
of  septic  arthritis.  The  treatment  in  a  non-suppurative  case  is 
the  same  as  in  ordinary  synovitis  (p.  395).  In  a  suppurative 
case,  treat  as  in  septic  arthritis  (p.  411). 

Gonorrhoea!  Arthritis,  or  Gonorrhoea!  Rheumatism. — 
During  the  progress  of  gonorrhoea  every  rheumatic  attack 
is  not  gonorrhoeal  rheumatism,  for  ordinary  rheumatism  may 
just  as  likely  arise  when  a  man  has  clap  as  when  he  has  not 
this  malady.  Furthermore,  the  term  is  bad,  as  gonorrhoeal 
rheumatism  is  not  rheumatism  at  all,  but  is  a  septic  or  an 
infective  disorder  of  the  joints  or  of  the  synovial  membranes, 
the  infective  material  being  contained  primarily  in  the  urethral 
discharge.  This  infective  arthritis  sometimes,  though  rarely, 
arises  during  the  height  of  a  gonorrhoea,  but  is  more  fre- 
quently met  with  in  chronic  cases  or  when  the  intensit}'  of 
the  inflammation  is  abating  in  acute  cases.  Men  suffer  from 
gonorrhoeal  rheumatism  far  more  frequently  than  do  women, 
and  the  seizure  is  very  apt  to  recur  again  and  again.  In 
some  cases  many  joints  are  involved,  but  in  most  cases  only 
a  few  joints  suffer.  Osier  states  that  the  knees  and  ankles 
are  most  apt  to  be  involved  in  a  gonorrhoeal  rheumatism, 
and  that  this  form  of  arthritis  is  peculiar  in  often  attacking 
joints  which  are  apt  to  be  exempt  in  acute  rheumatism  ("  the 
sterno-clavicular,  the  intervertebral,  the  temporo-maxillary, 
and  the  sacro-iliac  "). 

Changes  in  and  about  the  Joint. — The  inflammation  of 
gonorrhoeal  arthritis  may  be  located  around  rather  than  in 
the  joint,  and  especially  in  the  tendon-sheaths.  Suppuration 
is  unusual,  but  it  does  occur  in  joints  and  in  tendon- 
sheaths.     Cultivation  of  the  exudate  may  or  may  not  show 


DISEASES  AND   INJURIES    OF  BONES  AND  JOINTS.      413 

the  gonococci.  These  orcranisms  die  quickly  in  cultivations, 
and  it  requires  a  most  expert  bacteriologist  to  deny  or  affirm 
positively  their  presence.  Osier  suggests  that  the  non-sup- 
purative  cases  are  due  to  the  action  of  ptomaines  taken  up 
from  the  area  of  primary  infection,  and  that  the  suppurative 
cases  are  due  to  infection  with  pus  cocci. 

SymptoDis. — In  gonorrhoea!  arthritis  there  may  be  transi- 
tory, intermittent,  and  wandering  pains  in  and  about  the 
joint,  without  any  other  symptom ;  one  or  more  joints  may 
become  swollen  and  painful,  and  moderate  fever  may  develop. 
An  acute  inflammation  with  intense  pain  and  great  swelling 
may  attack  a  single  joint,  in  which  case  fever  will  be  mod- 
erate unless  suppuration  follows.  One  joint,  especially  the 
knee,  may  swell  up  to  an  enormous  extent,  pain,  periarticular 
oedema,  redness,  and  fever  being  absent  (hydrarthrosis,  or 
dropsy  of  a  joint).  Suppuration  in  this  form  is  rare.  The 
tendons,  the  tendon-sheaths,  the  bursge,  and  the  periosteum 
may  inflame.  A  case  of  gonorrhoeal  rheumatism  is  often 
very  hard  to  check.  It  may  last  for  long  periods,  and  tends 
to  recur  again  and  again.  Iritis,  pleuritis,  endocarditis,  and 
pericarditis  have  been  observed  as  complications. 

The  diagnosis  between  gonorrhoeal  rheumatism  and  acute 
rheumatism  rests  chiefly  on  the  great  chronicity,  the  slight 
degree  of  fever,  the  excessive  tendency  to  recurrence,  and 
the  absence  of  profuse  acid  sweats  in  gonorrhoeal  rheuma- 
tism ;  and  on  the  shorter  course,  the  higher  fever,  the  pro- 
fuse acid  sweats,  the  lesser  tendency  to  rapid  recurrence, 
the  greater  proneness  to  symmetrical  involvement,  and  the 
greater  frequency  of  cardiac  and  visceral  complications  in 
rheumatic  fever.  Furthermore,  in  gonorrhoeal  rheumatism  a 
urethral  discharge  certainly  exists  or  recently  existed ;  in 
ordinary  rheumatism  a  urethral  discharge  may,  of  course, 
happen  to  be  present.  Gonorrhoeal  rheumatism  is  apt  to 
affect  certain  joints  which  acute  rheumatism  rarely  attacks. 


414  A   MANUAL    OF  SURGERY. 

Treatment. — Internally,  in  treating  gonorrhoea!  rheuma- 
tism, the  salicylates,  the  alkalies,  salol,  and  iodide  of  potas- 
sium are  useless ;  iron,  arsenic,  strychnine,  and  quinine  are 
of  some  benefit.  In  suppurative  cases,  incise  and  drain  (see 
Septic  Arthritis^  ^.  4.11).  In  non-suppurative  cases,  treat  as 
in  synovitis  (p.  395).  In  lingering  cases,  employ  massage, 
passive  motion,  flying  blisters,  and  the  hot  iron ;  if  these 
means  fail,  open  the  joint,  wash  it  out  with  some  antiseptic 
fluid,  and  dress  antiseptically  (or  aspirate  and  inject). 

Rheumatic  Arthritis. — Acute  rheumatism  is  a  self-limited 
febrile  malady  whose  characteristic  features  are  polyarthritis, 
profuse  acid  sweats,  and  a  tendency  to  heart-involvement. 

Symptoms  of  Acute  Rlieiimatism. — In  acute  rheumatism  the 
case  begins  with  malaise  and  fever,  and  one  or  more  jomts 
become  affected.  The  inflammation  spreads  from  joint  to 
joint,  is  apt  to  be  symmetrical,  and  when  it  arises  in  fresh 
joints  it  is  apt  to  disappear  quickly  in  those  previously 
affected.  The  temperature  is  high,  the  skin  sweats  profusely, 
the  joints  are  red,  swollen,  hot,  and  excruciatingly  painful, 
and  the  structures  about  the  joint  are  cedematous.  After  a 
short  time  the  inflammation  subsides  in  one  joint  and  passes 
into  another,  the  joint  first  attacked  regaining  its  functions. 
Suppuration  does  not  take  place.  Anemia  is  pronounced, 
exhaustion  is  profound,  the  sweat  is  sour,  the  saliva  is  acid, 
the  urine  is  acid,  scanty,  high-colored,  often  contains  albumin, 
and  is  deficient  in  chlorides.  Cardiac  disease  is  apt  to  be 
caused  (endocarditis,  pericarditis,  or  myocarditis).  Nodules 
may  form  upon  fibrous  structures,  hyperpyrexia  is  not  unu- 
sual, and  cerebral  or  pulmonary  complications  may  occur. 
Chronic  rheumatism  rarely  follows  repeated  attacks  of  acute 
rheumatism,  but  arises  insidiously  in  people  who  have  been 
exposed  to  cold  and  damp,  who  have  suffered  from  poverty, 
hardship,  and  privation,  or  who  have  had  much  worry.  The 
capsule  and  the  tendon-sheaths  thicken,  and  there  is  usually 


DISEASES  AND  INJURIES   OF  BONES  AND  JOINTS.      415 

but  little  effusion  in  the  joint,  but  the  articulation  becomes 
stiff  and  painful.  The  joint-cartilages  are  occasionally  eroded. 
Muscular  atrophy  occurs. 

Symptoms  of  Chronic  Rlicuinatism. — Chronic  rheumatism 
is  indicated  when  the  affected  joints  are  stiff  and  painful  and 
are  a  little  swollen,  but  not  red.  Dampness  and  cold  aggra- 
vate the  symptoms.  One  joint  or  many  may  be  affected, 
but  usually  many  are  involved.  Passive  movements  cause 
the  joint  to  creak  and  develop  crepitus  in  the  tendon-sheaths. 
The  muscles  are  wasted.  The  joint  may  ankylose.  Ansmia 
is  usually  pronounced.  There  is  no  fever  and  no  tendency 
to  suppuration,  and  the  disease  is  incurable. 

The  treatment  in  acute  rheumatism  comprises  the  use  of 
alkalies,  salicylates,  etc.  (See  a  book  upon  medicine,  as  acute 
rheumatism  is  in  the  physician's  province.)  In  chronic 
rheumatism,  maintain  the  general  health  of  the  patient,  give 
courses  of  iron,  arsenic,  and  strychnine,  and  an  occasional 
course  of  iodide  of  potassium  or  a  salt  of  lithium,  and,  if 
possible,  send  him  every  winter  to  a  warm  climate.  Turkish 
baths  give  the  greatest  possible  relief  The  waters  and 
regimen  of  Carlsbad  and  Vichy  are  of  immense  though 
temporary  benefit.  The  patient  will  obtain  relief  at  the  hot 
springs  of  Virginia.  The  patient  must  avoid  damp  and 
must  wear  woollens.  Frictions,  the  douche,  massage,  flying 
blisters,  counter-irritation  with  the  hot  iron,  ichthyol  oint- 
ment, and  mercurial  ointment  are  of  benefit.  In  partial 
ankylosis,  give  ether  and  break  up  the  adhesions. 

Gouty  arthritis,  which  appears  especially  in  the  smaller 
joints  (as  the  fingers  and  the  metatarso-phalangeal  joint  of 
the  big  toe),  is  due  to  a  deposition  of  urate  of  sodium  in  the 
joint  and  in  the  periarticular  structures.  This  irritant  urate 
of  sodium^  causes  inflammation,  inflammation  forms  embry- 
onic tissue,  embryonic  tissue  is  converted  into  fibrous  tissue, 
and  the  fibrous  tissue  contracts  and  thus  deforms  the  joint 


4l6  A   MANUAL    OF  SURGERY. 

and  limits  its  mobility.  A  great  mass  of  urates  in  a  joint 
constitutes  a  "  chalk-stone." 

Symptoms. — The  premonitory  symptoms  may  be  observed 
for  a  day  or  so,  but  the  acute  seizure  occurs  early  in  the 
morning,  the  patient,  as  a  rule,  being  aroused  by  excruciat- 
ing pain  in  the  metatarso-phalangeal  articulation  of  the  great 
toe.  The  joint  swells,  and  the  skin  over  it  feels  hot  to  the 
hand  and  becomes  shiny.  There  is  considerable  fever.  After 
a  few  hours  the  ferocity  of  the  seizure  abates,  recurring 
again  with  renewed  violence  early  the  next  morning,  these 
remissions  and  recurrences  taking  place  for  six  or  eight 
days,  when  the  attack  subsides.  In  patients  with  chronic 
gout  many  joints  are  stiffened  and  deformed  as  a  result  of 
repeated  attacks.  Chalk-stones  form,  and  the  skin  above 
them  may  ulcerate.  Such  patients  are  chronic  dyspeptics, 
have  high-tension  pulses,  their  hearts  are  hypertrophied,  and 
their  urine  contains  albumin  and  casts. 

The  treatment  of  gouty  arthritis  belongs  to  the  physician, 
and  not  to  the  surgeon,  although  to  the  latter  the  disease 
should  be  known,  so  that  it  can  be  diagnosticated  from  other 
maladies. 

Arthritis  Deformans  (Rheumatoid  arthritis ;  Osteo-ar- 
thritis  ;  Rheumatic  gout). — In  this  disease,  which  is  not  a 
combination  of  gout  and  rheumatism,  the  synovial  mem- 
brane is  affected,  the  cartilages  are  diseased,  the  periarticular 
structures  are  involved,  and  masses  of  new  bone  are  formed. 

Arthritis  deformans  has,  as  Prof  John  K.  Mitchell  pointed 
out,  a  probable  nervous  origin.  It  arises  especially  in  per- 
sons who  have  been  worried,  driven,  and  harassed.  There 
is  apt  to  be  muscular  atrophy;  trophic  lesions  of  the  hair 
and  nails  are  likely  to  occur,  and  the  symptoms  are  dis- 
posed to  be  symmetrical.  The  causative  lesion  has  not  been 
determined.  Rheumatic  gout  is  commoner  in  women  than 
in  men.     The  greatest  liability  exists  between  the  ages  of 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      417 

twenty  and  thirty,  but  children  may  acquire  the  disease,  and 
it  may  also  be  developed  in  people  beyond  middle  life. 
Arthritis  deformans  may  attack  the  rich  or  the  poor;  it  does 
not  result  from  gout  nor  follow  rheumatism,  it  is  not  caused 
by  damp  and  cold,  and  it  does  not  arise  from  traumatism. 
Apes  in  captivity   may  develop  it. 

Arthritis  deformans  differs  from  gout  in  the  entire  absence 
of  urate  deposit,  and  it  differs  from  chronic  rheumatism  in 
the  extensive  alterations  in  the  joint-structures.  The  changes 
begin  in  the  cartilage;  the  cartilage-cells  multiply,  the  inter- 
cellular substance  degenerates,  the  pressure  of  the  bone  causes 
thinning,  and  at  length  the  cartilage  is  entirely  destroyed 
and  the  bone  is  exposed.  The  exposed  bone  is  altered  in 
shape,  is  hardened,  and  is  worn  away  in  the  centre,  the 
periphery  increasing  in  thickness  by  ossific  deposit ;  thus 
the  centre  becomes  deepened  by  absorption  and  the  periphery 
bulged  and  lengthened  by  deposit.  The  fringes  of  the  syno- 
vial membrane  hypertrophy  and  multiply,  and  some  of  them 
are  apt  to  break  off  (loose  cartilages).  The  capsule  and  the 
ligaments  of  the  joint,  as  a  rule,  become  fibrous  and  con- 
tract, but  they  may  soften,  relax,  and  permit  of  dislocation. 
The  joint  usually  contains  no  effusion,  but  in  some  cases 
there  is  great  effusion  (hydrarthrosis).  The  tendons  about 
the  joint  may  become  fibrous  and  contracted,  they  may 
ossify,  they  may  be  separated  from  the  bone,  or  they  may 
be  destroyed  entirely.  Deformity  is  marked  and  m.otion  is 
limited.  The  fingers,  when  involved,  show  nodules  on  the 
sides  of  the  joints  (Heberden's  nodules).  The  vertebrae 
may  be  involved.  Almost  all  the  joints  may  suffer.  Sup- 
puration does  not  occur. 

Symptoms. — Charcot  classifies  arthritis  deformans  into 
three  forms,  and  gives  their  symptoms  as  follows  : 

(i)  Heberden's  nodosities,  which  condition  is  commoner  in 
women  than  in  men,  comes  on  between  the  ages  of  thirty 

27 


4l8  ^1    MANUAL    OF  SURGERY. 

aiul  forty,  and  is  especially  common  in  neurotic  subjects. 
The  interphalangeal  joints  become  the  victims  of  attacks  of 
moderate  swelling  and  of  some  tenderness,  which  attacks 
are  not  severe,  but  recur  again  and  again.  After  a  time 
small  hard  swellings  (nodosities)  appear  upon  the  sides  of 
the  dorsal  surfaces  of  the  second  and  third  phalanges,  re- 
main permanently,  and  slowly  increase  in  size.  The  joints 
become  stiff  and  creak  on  movement,  the  cartilage  is  de- 
stroyed, and  contractions  and  rigidity  develop,  but  there  is 
no  fever  and  the  larger  joints  are  not  involved.  The  malady 
is  incurable. 

(2)  Progressive  rlieuniatic  gout,  which  may  be  acute  or 
chronic.  The  acute  form  begins  as  does  rheumatic  fever. 
There  are  moderate  fever,  and-  swelling,  but  no  redness,  of  a 
number  of  joints,  of  bursae,  and  of  tendon-sheaths  ;  the  joints 
are  stiff  and  crepitate,  and  are  apt  to  be  symmetrically  in- 
volved ;  muscular  atrophy  begins  early  and  rapidly  becomes 
decided;  pain  is  slight.  This  acute  form  is  apt  to  arise 
in  young  women  after  pregnancy,  but  is  not  unusual  at  the 
climacteric  and  in  children.  Anaemia  always  exists.  The 
case  is  apt  to  advance  progressively  until  a  number  of  joints 
are  firmly  locked,  when  it  may  become  stationary.  A  fresh 
pregnancy  will  develop  anew  the  acute  symptoms.  In  the 
clironic  form  swelling  and  pain  on  movement  are  noted  in 
certain  joints.  The  involvement  is  apt  to  be  symmetrical. 
Attacks  of  swelling  and  pain  alternate  with  periods  of  quies- 
cence, but  the  disease  does  not  cease  its  advance.  Articu- 
lation after  articulation  is  attacked  by  the  malady  until  almost 
all  the  joints  are  involved ;  deformity  and  stiffness  become 
pronounced,  and  pain  may  or  may  not  be  severe.  There  is 
no  fever.      Muscular  atrophy  is  marked. 

(3)  Partial  rheumatic  gout  attacks  one  articulation,  and  it 
is  most  often  met  with  in  old  men.  It  may  fix  itself  on  the 
vertebral    column,  on    the    knee,  on    the    shoulder,  on   the 


DISEASES   AND    INJURIES    OE  BONES  AND  JOINTS.      4I9 

elbow,  or  on  the  hip.  The  joint  grates  and  becomes  stiff, 
swollen,  and  deformed ;  the  muscles  atrophy ;  there  is 
usually  pain,  but  fever  is  absent.  Partial  rheumatic  gout 
of  the  hip-joint  in  an  old  person  is  known  as  "  morbus  coxae 
senilis,"  and  partial  rheumatic  gout  of  the  vertebral  articu- 
lations causing  fixation  is  called  ''  spondylitis  deformans." 

TrcatmcJit. — Rheumatic  gout  cannot  be  cured,  but  in  some 
cases  it  remains  stationary  for  many  years.  Treat  the  anaemia 
by  iron,  arsenic,  good  food,  and  fresh  air.  Debility  is  met  by 
strychnia.  Hot  baths  of  mineral  water  do  good.  Massage 
retards  the  progress  of  the  case,  relieves  the  pain,  helps  the 
absorption  of  the  effusion,  and  delays  fixation.  During  an 
acute  exacerbation  the  joint  should  be  put  at  rest  for  a  day 
or  two,  and  there  should  be  used  lead-water  and  laudanum, 
cold  water,  or  tincture  of  arnica.  Douches  and  hot  baths 
improve  these  cases,  but  electricity  is  entirely  useless. 
Counter-irritants  do  no  good.  The  patient  is  unfortunately 
liable  to  develop  the  opium  habit.  In  dropsy  of  a  joint,  if  it 
arises,  try  compression  with  a  Martin  bandage,  and  if  this 
fails,  aspirate  and  inject  carbolic  acid.  Patients  with  rheu- 
matic gout  do  best  in  a  warm  dry  climate.  Cod-liver  oil 
does  good,  as  it  improves  nutrition  and  hence  retards  the 
progress  of  the  disease.  Do  not  be  tempted  to  immobilize 
the  joints  beyond  a  day  or  two :  fixation  only  hastens 
ankylosis. 

Charcot's  Disease  (Tabetic  arthropathy;  Charcot's  joint; 
Neuropathic  arthritis). — This  condition  is  an  osteo-arthritis 
due  to  trophic  disturbance,  arising  in  a  sufferer  from  loco- 
motor ataxia,  and  is  anatomically  identical  with  rheumatic 
gout.  The  knee  is  most  apt  to  be  attacked.  The  disease  begins 
acutely,  often  as  a  sudden  effusion  which  after  a  time  disap- 
pears. Pain  is  slight  or  is  absent,  there  is  no  constitutional 
involvement,  and  the  condition  is  unconnected  with  injury. 
The  bones  and  cartilages  are  rapidly  destroyed ;  fracture  is 


420  A   MANUAL    OF  SUKGEKY. 

apt  to  occur;  the  joint  creaks  and  grates;  the  softening  and 
relaxation  of  hgaments  permit  an  extensive  range  of  move- 
ment; great  deformity  ensues;  dislocation  is  apt  to  occur; 
muscular  atrophy  is  decided  ;  and  pus  occasionally,  though 
very  rarely,  forms. 

TrcatmeJit. — The  treatment  of  Charcot's  disease  consists 
in  the  wearing  of  an  apparatus  to  sustain  the  joint.  Re- 
section is  recommended  by  some,  but  most  surgeons  do  not 
advise  its  performance. 

Hysterical  joint  (Brodie's  joint)  is  a  condition  mostly 
encountered  in  young  women.  The  disease  occurs  in  the 
knee  and  the  hip,  and  often  follows  a  slight  injury  which 
acts  as  an  auto-suggestion,  a  latent  hysteria  being  awakened 
into  action  and  localized,  though  severity  of  the  injury  does 
not  determine  the  severity  of  the  symptoms.  The  disease  may 
ensue  upon  an  arthritis  or  may  arise  without  apparent  cause. 
The  patient  resists  passive  motion  strenuously  and  claims 
that  it  causes  much  pain.  There  is  occasionally  some  mus- 
cular atrophy  from  want  of  use,  and  the  joint  is  a  little 
swollen.  The  skin  is  hyperaesthetic,  and  a  light  touch 
causes  more  pain  than  does  deep  pressure.  The  muscles 
may  be  rigid.  The  joint  may  be  maintained  either  in  flexion 
or  in  extension,  but  it  is  rarely  in  the  exact  degree  of  flexion 
assumed  for  ease  in  a  true  joint-inflammation,  and  the  position 
is  apt  to  be  changed  from  day  to  day  or  from  hour  to  hour. 
The  skin  is  usually  cool,  but  may  be  hot,  and  a  periodically 
developed  heat  may  be  observed,  especially  at  night,  accom- 
panied apparently  by  much  pain.  The  pain  in  some  cases  is 
a  neuralgia,  but  in  most  cases  is  a  pain  hallucination.  In 
some  rare  cases  organic  disease  arises  in  a  hysterical  joint. 

Hysterical  phenomena  are  seldom  isolated,  but  are  asso- 
ciated with  certain  stigmata  which  may  be  latent.  These 
stigmata  are  concentric  contraction  of  the  visual  fields, 
pharyngeal    anaesthesia,    convulsions,    hysterogenic    zones, 


DISEASES  AND    INJURIES   OF  BONES  AND  JOINTS.      42 1 

globus  hystericus,  clavus  hystericus,  zones  of  anaesthesia, 
especially  hemianaesthesia  and  hyperaesthetic  areas.  Such 
patients  are  predisposed  by  inheritance,  and  have  previously, 
as  a  rule,  had  nervous  troubles.  Hysterical  phenomena,  be 
it  remembered,  lack  regularity  of  evolution,  and  are  pro- 
duced, altered,  or  abolished  by  mental  influences  and  physi- 
cal sensations  which  are  without  effect  in  causing,  modifying, 
or  curing  organic  disease.  The  general  health,  as  a  rule,  is 
good,  but  neurasthenia  may  coexist.  In  examining  these 
patients  the  observer  will  note  that  the  symptoms  disappear 
when  the  attention  is  diverted,  that  they  are  out  of  all 
proportion  to  the  local  evidences  of  the  disease,  that  there 
is  no  evidence  of  joint-destruction,  and  that  light  touching 
causes  more  pain  than  does  firm  pressure.  If  the  patient  is 
anaesthetized,  perfect  joint-mobility  will  be  found. 

Treatment. — The  treatment  in  hysterical  joints  comprises 
attention  to  the  general  health,  the  employment  of  nourishing 
and  easily-digested  food,  the  prevention  of  constipation,  and 
the  administration  of  tonics  if  they  are  needed.  The  sur- 
geon must  dominate  his  patient's  mind  and  make  her  realize 
that  he  is  master  of  the  case.  He  is  to  be  an  inexorable  but 
just  ruler — never  a  brutal  or  a  cruel  one.  If  possible,  send 
the  patient  away  from  the  sympathies  of  her  home  and  let 
her  have  the  rest  treatment  of  Weir  Mitchell.  Local  rem- 
edies applied  to  the  joint  do  harm,  as  a  rule,  by  concentrating 
afresh  the  patient's  attention  upon  the  articulation,  although 
the  hot  iron  sometimes  does  good.  Suggestion  in  the  hyp- 
notic state  may  be  tried.  The  use  of  morphia  should  be 
avoided  as  being  the  worst  of  enemies.  Never  immobilize 
the  joint,  and  always  use  massage,  passive  motions,  and 
frictions. 

Neuralgia  of  the  joints  as  an  independent,  isolated  affec- 
tion is  extremely  rare,  though  as  a  complication  of  other  dis- 
eases it  is  by  no  means  uncommon.     The  neuralgia  is  more 


422  A    MANUAL    OF  SURGERY. 

often  around  the  joints  than  in  them,  and  is  especially  frequent 
in  the  knee  and  the  ankle.  Joint- neuralgia  may  arise  in  any 
person,  but  it  is  more  commonly  present  in  young  neurotic 
females.  The  pain  may  be  persistent  or  it  may  occur  in 
periodic  storms,  and  it  is  often  linked  with  neuralgia  in 
other  parts.  The  pain  may  be  dull  and  aching,  but  it  is 
more  often  sharp  and  shooting.  Joint-neuralgia  is  associated 
with  tenderness  on  pressure,  soreness  on  motion,  often  with 
transitory  swelling  without  redness,  and  sometimes  with 
numbness  of  the  extremity.  The  diagnosis  depends  on  the 
temperament  of  the  patient,  the  sudden  onset  of  the  pain, 
the  absence  of  constitutional  symptoms,  and  the  free  mobility 
of  the  joint,  especially  under  ether.  Articular  neuralgia  may 
depend  upon  disease  or  injury  of  the  central  nervous  system, 
upon  malaria,  syphilis,  neurasthenia,  rheumatism,  gout, 
hysteria,  and  neuritis,  and  may  be  due  to  reflected  irritation, 
especially  from  the  ovaries,  the  womb,  and  the  rectum. 

Treatment. — The  treatment  to  be  observed  in  joint-neural- 
gia is  to  maintain  the  general  health  ;  examine  for  a  possible 
exciting  cause,  and,  if  found,  remove  it ;  give  a  long  course 
of  iron,  quinine,  and  strychnine  or  of  arsenic.  In  rheumatic 
or  gouty  subjects  give  suitable  drugs  and  insist  upon  proper 
diet.  During  the  attack  use  phenacetin.  Morphia  must 
occasionally  be  used  in  severe  cases,  but  be  careful  of  it, 
and  never  tell  the  patients  they  are  taking  it,  as  there  is  a 
liability  of  their  forming  the  opium  habit.  Locally,  employ 
frictions,  ointment  of  aconite,  and  heat,  and  keep  upon  the 
part  a  piece  of  flannel  soaked  in  a  mixture  of  soap  liniment, 
laudanum,  and  chloroform  (Gross).  Never  let  a  joint  stiffen  ; 
any  tendency  to  do  so  should  be  met  by  daily  massage,  fric- 
tions, passive  motion,  and  the  hot  and  cold  douche.  In 
some  rare  cases  nerve-stretching  or  neurectomy  becomes 
necessary. 

Articular    Wounds    and    Injuries. — A    non-penetrating 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      423 

wound  requires  antiseptic  irrigation,  stitching,  and  antiseptic 
dressing  upon  a  splint.  A  penetrating  wound  is  very  serious, 
and  it  may  be  due  to  compound  fracture  (p.  307),  to  com- 
pound dislocation  (p.  435),  to  gunshot  wounds,  or  to  stabs. 
If  a  bursa  near  a  joint  be  injured,  secondary  penetration  may 
occur  as  a  result  of  suppuration.  In  a  penetrating  wound, 
besides  pain,  hemorrhage,  and  swelling,  there  is  a  flow  of 
synovial  fluid.  A  small  amount  of  synovia  flows  from  an 
injured  bursa,  a  large  amount  from  an  open  joint. 

Treatment. — If  a  joint  is  opened  aseptically  (as  when  incised 
by  the  surgeon),  it  gets  well  nicely  under  rest  and  antisepsis. 
If  a  joint  is  opened  by  a  septic  body,  suppurative  arthritis 
is  apt  to  arise,  and  the  indications  are  to  irrigate,  drain, 
dress  antisepticaliy,  and  secure  rest.  In  gunshot  wounds,  if 
antisepsis  is  not  employed,  suppuration  is  inevitable ;  hence 
military  surgeons,  as  a  rule,  have  advocated  amputation  or 
excision  in  gunshot  splinterings  of  large  joints.  In  these 
injuries  the  wound  is  enlarged,  the  finger  is  introduced  to 
discover  and  remove  foreign  bodies,  through-and-through 
drainage  is  secured,  a  tube  is  inserted,  the  joint  is  irrigated, 
antiseptic  dressings  are  applied,  and  the  extremity  is  placed 
upon  a  splint.  Very  severe  cases  demand  resection  or  even 
amputation.  Ankylosis  more  or  less  complete  follows  a 
gunshot  wound  of  a  joint.  If  the  joint  suppurates,  the 
drainage  must  be  made  more  free,  sinuses  must  be  slit  up 
and  packed,  sloughs  must  be  cut  away,  dead  bone  must  be 
gouged  out,  and  the  patient  must  be  placed  upon  a  stimu- 
lant and  tonic  plan   of  treatment. 

Sprains. — A  sprain  is  a  joint-wrench  due  to  a  sudden 
twist  or  traction,  the  ligaments  being  pulled  upon  or  lace- 
rated and  the  surrounding  parts  being  more  or  less  damaged, 
A  sprain  is  often  a  self-reduced  dislocation.  The  joints  most 
liable  to  sprains  are  the  knee,  the  elbow,  and  the  ankle. 
The  smaller  joints  are  also  often  sprained,  but  the  ball-and- 


424  A    MANUAL    OF  SURGERY. 

socket  joints  arc  infrequently  sprained,  their  normal  rani:^e 
of  free  mov^ement  saving  them  ;  they  do  occasionally  suffer 
severely,  however,  as  a  result  of  abduction.  In  a  bad  sprain 
the  ligaments  are  torn  ;  the  synovial  membrane  is  contused 
or  crushed ;  hemorrhage  takes  place  into  and  about  the 
joint ;  muscles  and  tendons  are  stretched,  displaced,  or 
lacerated  ;  vessels  and  nerves  are  damaged;  the  skin  is  often 
contused  ;  and  portions  of  bone  or  cartilage  may  be  detached 
from  their  proper  habitat,  though  still  adhering  to  a  liga- 
ment (sprain-fractures).  Sprains  are  commonest  in  young 
persons  and  in  adults.  A  joint  once  sprained  is  very  liable 
to  a  repetition  of  the  damage  from  slight  force.  Sprains  are 
common  in  a  limb  with  weak  muscles,  in  a  deformed  extrem- 
ity in  which  the  muscles  act  in  unnatural  lines,  and  in  a  joint 
with  relaxed  ligaments. 

Symptoms. — The  symptoms  manifested  in  sprains  are  as 
follows :  severe  pain  in  the  joint,  accompanied  by  weak- 
ness, nausea,  often  by  vomiting,  and  sometimes  by  syncope. 
Impairment  or  loss  of  motion  is  present.  This  condition  is 
succeeded  by  a  season  of  relief  from  pain  while  at  rest, 
numbness  being  complained  of,  and  pain  on  motion  being 
severe.  Very  soon  swelling  begins  if  hemorrhage  is  severe. 
In  any  case  swelling  begins  in  a  few  hours.  Movement  of 
the  joint  becomes  difficult  or  impossible ;  the  tear  in  the 
ligament  may  be  distinctly  felt ;  pain  and  tenderness  become 
intense ;  joint-crepitus  will  be  detected  ;  and  in  a  day  or  two 
discoloration  becomes  marked. 

Diagnosis  and  Progiiosis. — Sprain-fractures  cannot  be  diag- 
nosticated with  certainty.  The  diagnosis  must  be  made 
from  fracture  and  dislocation.  In  fracture,  crepitus  and 
mobility  exist ;  in  dislocation,  rigidity.  The  diagnosis  should 
be  made  by  a  consideration  of  the  joint  involved,  of  the  age, 
of  the  nature  of  the  force,  by  the  length  of  the  limb,  by  the 
fact  that  the  patient  could  use  the  joint  for  at  least  a  short 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      425 

time  after  the  accident,  and  by  the  local  feel  and  movements 
of  the  part.  The  prognosis  depends  on  the  size  ot  the  joint, 
on  the  extent  of  laceration,  and  on  the  amount  of  intra- 
articular hemorrhage.     The  danger  is  ankylosis. 

Trcatnicnt. — The  indications  are,  first,  to  limit  inflamma- 
tion, and,  secondly,  to  restore  the  functions  of  the  joint. 
In  a  mild  sprain  use  lead-water  and  laudanum  or  apply  at 
once  a  silicate  dressing.  In  a  severe  sprain  place  the  extrem- 
ity upon  a  splint  and  to  the  joint  apply  flannel  kept  wet 
with  lead- water  and  laudanum,  iced  water,  tincture  of  arnica, 
alcohol  and  water,  or  a  solution  of  chloride  of  ammonium. 
The  ice-bag  should  from  time  to  time  be  laid  upon  the 
flannel  for  periods  of  twenty  or  thirty  minutes.  Leeches 
around  the  joint  do  good.  Constitutionally,  employ  the  rem- 
edies for  inflammation  (p.  60).  Morphia  or  Dover's  powder 
is  given  for  the  pain.  Judicious  bandaging  limits  the  swell- 
ing. 

After  a  day  or  two,  if  the  symptoms  continue  or  if  they 
grow  worse,  use  hot  fomentations,  hot  lead-water  and  lauda- 
num, the  hot-water  bag,  plunge  the  extremity  frequently  in 
very  hot  water,  or  apply  heat  by  Leiter's  tubes.  When  the 
acute  symptoms  begin  to  subside,  rub  stimulating  liniments 
upon  the  joint  once  or  twice  a  day  and  employ  firm  com- 
pression by  means  of  a  bandage.  Many  cases  do  well  at 
this  stage  under  the  local  use  of  ichthyol  and  lanolin  (50 
per  cent.),  tincture  of  iodine,  or  blue  ointment.  Later  in 
the  case,  use  the  hot  and  cold  douche,  massage,  frictions, 
passive  motion,  and  the  bandage.  Give  iodide  of  potassium, 
often  use  tonics  internally,  and  insist  on  open-air  exercise. 
Many  sprains  may  be  put  up  in  an  immovable  dressing 
about  the  first  day  or  two  after  the  accident.  If  the  joint 
contains  much  blood,  aspiration  should  be  practised  before 
the  dressing  is  applied. 

Ankylosis. — When    a  joint-inflammation    eventuates    in 


426  A    MANUAL    OF  SURGERY. 

the  formation  of  new  tissue  in  and  about  the  joint,  contrac- 
tion of  this  tissue  Hmits  or  destroys  joint-mobility,  producing 
the  condition  known  as  "  ankylosis."  Ankylosis  may  be 
complete  (bony)  or  incomplete  (fibrous);  it  may  arise  from 
contractures  in  the  joint  (true  or  intra-articular  ankylosis) 
or  from  contractures  in  the  structures  external  to  the  joint 
(false  or  extra-articular  ankylosis). 

True  or  intra-articular  ankylosis  may  arise  from  any  cause 
which  produces  joint-inflammation  with  formation  of  new 
tissue,  and  may  be  due  to  wounds,  contusions,  sprains,  dis- 
locations, fractures  in  or  near  a  joint,  movable  bodies  in  a 
joint,  tubercle,  gout,  rheumatism,  or  syphilis.  Want  of  use 
of  the  joints  causes  partial  ankylosis,  though  this  has  been 
denied.  Ankylosis  is  more  apt  to  take  place  in  a  hinge- 
joint  than  in  a  ball-and-socket  joint.  In  ankylosis  from  a 
general  cause  (as  rheumatic  gout)  many  joints  are  apt  to 
suffer.  Ankylosis  may  be  due  to  fibrous  tissue,  and  is  then 
usually  partial ;  it  may  be  due  to  chondrification  of  fibrous 
tissue,  and  is  then  incomplete ;  it  may  be  due  to  ossification 
of  fibrous  tissue,  and  is  then  complete,  the  joint  being 
entirely  immobile  (osseous  or  bony  ankylosis).  The  entire 
joint  may  be  converted  into  bone.  Only  one  small  joint- 
surface  may  contain  adhesions  (limited  adhesion),  or  the 
entire  joint-surface  may  be  bound  up  in  them  (diffused  ad- 
hesion). 

Fibrous  ankylosis  follows  aseptic  inflammations ;  bony 
ankylosis  is  apt  to  follow  infections.  Though  some  motion 
is  usually  possible  in  fibrous  ankylosis,  in  some  cases  it  may 
be  impossible.  A  joint  immovable  from  fibrous  ankylosis  is 
distinguished  from  a  joint  immovable  from  bony  ankylosis 
by  the  fact  that  in  the  former  attempts  at 'motion  are  pro- 
ductive of  pain,  and  subsequently  of  inflammation.  The 
incapacity  resulting  from  ankylosis  is  due,  first,  to  the 
impairment  or  destruction  of  joint-function,  and,  secondly. 


DISEASES  AND    INJURIES   OF  BONES  AND  JOINTS.      427 

to  the  fixation  at  an  inconvenient  angle  (a  fixed  flexed  knee 
is  worse  than  a  fixed  extended  knee  ;  a  fixed  extended  elbow 
is  worse  than  a  fixed  flexed  elbow). 

Treatuioit. — The  effort  should  always  be  made  to  pre- 
vent an  ankylosis  by  treating  carefully  any  joint-inflamma- 
tion and  by  beginning  passive  motion  at  the  earliest  safe 
period.  To  limit  inflammation  is  to  prevent  ankylosis. 
Many  cases  of  fibrous  ankylosis  are  improved  by  passive 
movements,  massage,  frictions,  stimulating  liniments,  inunc- 
tions of  ichthyol  or  mercurial  ointment,  hot  and  cold 
douches,  and  electricity.  Some  cases  may  be  straightened 
out  slowly  by  screw-splints  or  by  weights  and  pulleys. 
Fibrous  ankylosis  of  the  elbow  is  best  treated  by  using 
the  joint.  Fibrous  ankylosis  is  often  corrected  by  forcible 
straightening.  If  the  tendons  are  much  contracted,  tenot- 
omy should  be  performed  two  or  three  days  before  forcible 
straightening  is  attempted.  In  order  to  straighten,  always 
give  ether.  Suppose  a  case  of  ankylosis  of  the  knee:  put 
the  patient  upon  his  back,  bring  the  leg  over  the  end  of 
the  operating-table,  grasp  the  ankle  with  one  hand  and 
the  lower  portion  of  the  leg  with  the  other  hand,  and 
make  strong  steady  movements  of  flexion  and  extension 
until  the  limb  can  be  straightened.  The  adhesions  will 
be  felt  to  break,  the  snapping  often  being  audible.  At 
once  apply  a  plaster-of-Paris  dressing,  and  keep  the  limb 
immobile  for  two  weeks.  This  procedure  is  not  free  from 
danger.  Vessels  may  be  ruptured,  nerves  may  be  torn,  skin 
and  fascia  may  be  lacerated,  suppuration  may  ensue  from  the 
admission  into  the  joint  of  encapsuled  cocci,  or  organisms 
in  the  blood  may  find  this  area  a  point  of  least  resistance. 
Because  of  the  danger  of  opening  up  depots  of  encapsuled 
bacilli  and  cocci,  do  not  forcibly  break  up  an  ankylosis  that 
results  from  a  tubercular  or  a  septic  arthritis,  but  use  gradual 
extension  by  weights  or  by  screw-splints.     Ankylosis  of  the 


428  A    MANUAL    OF  SURGERY. 

knee  following  fracture  of  the  patella  is  almost  sure  to  recur 
after  forcible  breaking  up.  The  best  treatment  for  knee- 
ankylosis  is  use  of  the  joint.  In  bony  ankylosis  of  any  joint 
other  than  the  elbow-joint,  do  nothing  if  the  joint  is  in  a 
useful  position.  If  the  joint  is  in  an  unfortunate  position, 
resort  to  excision  or  an  osteotomy.  In  the  elbow,  excision 
should  be  performed,  no  matter  what  the  position,  in  the 
hope  of  obtaining  a  movable  joint. 

False  or  Extra-articalar  Ankylosis. — In  this  disease  the 
joint  is  intact,  but  the  contractures  are  in  surrounding 
parts.  The  causes  are  muscular  and  tendinous  contractures, 
cicatrices  (especially  from  burns),  deposits  of  bone,  muscular 
paralysis,  tumors,  and  aneurysm.  Contractions  of  muscles 
or  tendons  may  be  due  to  gout,  rheumatism,  injury,  thecitis, 
fractures,  and  dislocations.  False  ankylosis  is  seen  in  club- 
foot  and  in  Dupuytren's  contraction. 

Ti'eatmcnt. — The  treatment  of  false  ankylosis  depends 
upon  the  cause.  Recently-contracted  muscles  or  tendons 
require  motions,  massage,  frictions  with  stimulating  liniments, 
and  the  hot  and  cold  douche.  Old  contractions  require 
division.  Whenever  possible,  excise  a  cicatrix  that  causes 
false  ankylosis,  and  fill  the  gap  with  good  tissue.  Bony 
deposits  are  gouged  away  and  tumors  are  removed.  Paralysis 
requires  electricity,  passive  motion,  frictions  with  stimulating 
liniments,  and  general  treatment. 

Loose  Bodies  in  Joints  (Floating-  Cartilag-es). — In  this 
affection  the  knee  is  the  joint  oftenest  affected.  These 
bodies  may  be  free,  may  have  a  stalk  or  pedicle,  may  move 
about  and  occasionally  block  the  joint,  or  may  lie  quietly 
in  a  joint-recess  or  diverticulum.  They  may  be  single 
or  multiple,  flat  or  ovoid,  smooth  or  irregular,  as  small  as 
peas  or  as  large  as  plums,  and  may  be  composed  of  fibrous 
tissue,  of  bone,  or  of  cartilage.  There  are  numerous  differ- 
ent modes  of  origin  of  these  bodies,  many  being  "  detached 


DISEASES  AND   EYJi'RIES   OF  BONES  AND  JOINTS.      429 

ecchondroses  or  pieces  of  hyaline  cartilage  hanging  by- 
narrow  pedicles  "  (Bland  Sutton),  and  they  result  from  en- 
largement and  chondrification  of  the  villi  of  the  synovial 
membrane.  Some  loose  bodies  are  broken-off  osteophytes ; 
some  arise  from  blood-clots  ;  some  by  projection  or  hernia- 
tion of  the  synovial  membrane,  which  protrusion  is  broken 
off;  others  are  detached  fringes  of  tubercular  synovial  mem- 
brane. Traumatism  is  usually  an  exciting  cause.  Loose 
cartilages  are  commonest  in  adult  men. 

Syuiptoms. — Many  small  bodies  give  rise  to  no  symptoms 
other  than  those  of  synovitis.  A  large  body  produces  pain 
and  interferes  with  joint-function.  The  joint  is  weak  and 
a  little  swollen,  and  the  patient  can  feel  the  body  and  often 
can  push  it  into  a  superficial  area  of  the  joint,  where  it  can 
be  felt  by  the  surgeon.  From  time  to  time  the  body  may 
get  caught,  thus  suddenly  locking  the  joint  and  producing 
intense  and  sickening  pain,  extension  and  flexion  being 
impossible  until  the  body  slips  out,  and  inflammation  and 
effusion  following  the  accident. 

Trcatuicnt. — To  relieve  locking,  employ  forced  flexion  and 
sudden  extension.  Cure  can  be  obtained  only  by  operation. 
Let  the  patient  bring  the  foreign  body  to  a  point  where  it 
can  be  felt;  the  surgeon  then  fixes  it  with  a  pin  or  holds  it 
with  the  fingers,  ether  being  given  or  cocaine  being  used. 
The  joint  is  now  opened,  the  foreign  body  extracted,  and  an 
exploration  is  made  to  see  that  no  other  bodies  are  present. 
The  wound  is  now  stitched  and  the  leg  is  placed  upon  a 
splint.  Antisepsis  must  be  most  rigid.  The  operation  does 
not  cure  the  causative  lesion,  and  these  bodies  are  apt  to 
form  again. 

4.  Luxations  or  Dislocations. 
A  dislocation  is  the  persistent  separation  from  each  other, 
partially  or  completely,  of  two  articular  surfaces.     A  sprain 


430  A   MANUAL    OF  SUA'GERY. 

is  a  self-reduced  dislocation.  There  are  three  forms  of  dis- 
location :  (i)  traumatic;  (2)  spontaneous  or  pathological; 
and   (3)  congenital. 

I.  Traumatic  dislocations  are  due  to  injury.  They  are 
divided  into — complete  dislocation,  in  which  the  two  articular 
surfaces  are  entirely  separated  and  the  ligaments  are  torn ; 
incomplete  or  partial  dislocation,  in  which  the  two  articular 
surfaces  are  not  completely  separated  and  the  ligaments  are 
rarely  lacerated  ;  simple  dislocation,  in  which  the  articular 
surfaces  are  not  brought  into  contact  with  the  external  air; 
compound  dislocation,  in  which  the  external  air  has  access  to 
the  articular  surfaces;  complicated  dislocation,  in  which, 
besides  the  dislocation,  there  is  a  fracture,  extensive  drainage 
of  the  soft  parts,  an  opening  admitting  air  to  the  soft  parts,  or 
damage  of  a  nerve  or  blood-vessel ;  primitive  dislocation,  in 
which  the  bones  remain  as  originally  displaced  ;  secondary 
dislocation,  in  which  the  bone  assumes  a  new  position : 
for  instance,  a  subglenoid  luxation  of  the  humerus  is 
primary,  and  it  may  become  secondarily  a  subcoracoid 
luxation  because  of  muscular  contraction  or  attempts  at 
reduction  ;  recent  dislocation,  in  which  the  displaced  bone 
is  not  firmly  fastened  by  tissue-changes  in  its  new  situa- 
tion, and  its  old  socket  is  not  obliterated  ;  old  dislocation,  in 
which  the  displaced  bone  is  firmly  fastened  by  tissue-changes 
in  its  new  habitat,  and  the  old  socket  is  to  a  great  extent 
obliterated  (whether  a  dislocation  is  old  or  new  depends  on 
the  state  of  the  parts  rather  than  on  the  time  which  has 
elapsed  since  the  accident) ;  double  dislocation,  in  which 
corresponding  bones  on  each  side  are  dislocated  ;  single  dis- 
location, in  which  only  one  joint  is  dislocated  ;  nndateral  dis- 
location, in  which  one  articulation  of  one  bone  is  out  of 
place;  bilateral  dislocation,  in  which  symmetrical  articula- 
tions are  dislocated  ;  and  relapsing  or  habitual  dislocation, 
which  recurs  constantly  from  slight  force  because  of  relaxed 


DISEASES  A. YD   EV/CA'/ES   OF  BONES  AND  JOEVTS.      43 1 

ligaments  or  lack  of  complete  repair  after  the  ligamentous 
rupture  of  a  first  dislocation. 

2.  Spontaneous,  Patholog-ical,  or  Consecutive  Disloca- 
tions.— Spontaneous  dislocation  arises  from  such  very  slight 
force  that  it  often  cannot  be  identified,  and  it  acts  on  a  joint 
rendered  lax  by  disease.  It  may  arise  in  the  course  of 
chronic  synovitis  and  during  tubercular  joint-disease.  In 
Charcot's  joint  [arthropatliic  dcs  ataxiqites)  this  form  of  dis- 
location constantly  appears.  This  condition  comes  on  in  a 
few  hours,  during  the  progress  of  locomotor  ataxia,  and  is 
without  apparent  reason.  The  knee,  the  shoulder,  or  some 
other  joint  becomes  greatly  swollen,  fluid  gathers  in  large 
amount,  the  ligaments  relax,  the  joint  is  destroyed  and 
becomes  excessively  mobile,  but  there  is  no  pain,  no  fever, 
and  no  sign  of  inflammation. 

3.  Cong-enital  Dislocations. — The  third  form,  or  congen- 
ital dislocation,  is  due  to  a  congenital  joint-malformation 
which  renders  it  impossible  for  the  bone  to  maintain  a  nor- 
mal position,  or  is  due  to  external  violence  during  the  period 
of  uterine  gestation.  Congenital  dislocations  should  not  be 
confounded  with  dislocations  produced  during  delivery. 

Traumatic  Dislocations. — In  the  succeeding  pages  the 
traumatic  form  of  dislocations  will  particularly  be  considered. 
The  causes  of  traumatic  dislocations  are  divided  into  predis- 
posing and  exciting. 

Predisposing  causes  are  (i)  Age — dislocations  are  com- 
monest in  middle  life  the  usual  lesion  of  the  young  being 
green-stick  fracture,  and  that  of  the  old  being  fracture. 
Dislocations  of  the  radius  are  not  uncommon  in  youth. 
(2)  Muscular  development — dislocations  being  commonest  in 
those  with  powerful  muscles.  (3)  Sex — males  being  more 
predisposed  than  females,  because  of  their  occupations  and 
muscular  strength.  (4)  Occupation  predisposes  as  a  cause 
according  as  it  demands  the  employment  of  muscular  force, 


432  A    MANUAL    OF  SURGERY. 

as  in  the  carrying  of  burdens.  (5)  Nature  of  the  joint — 
ball-and-socket  joints  being  more  liable  to  luxation  than  are 
ginglymus  joints,  because  of  their  wide  range  of  motion. 
(6)  Joint  disease  predisposes  by  relaxing  the  ligaments.  (7) 
Situation  of  the  joint — some  joints  being  more  exposed  to 
injury  than  others. 

Exciting  causes  are  classified  into  (i)  external  violence 
and  (2)  muscular  action.  External  violence  may  be  direct, 
as  when  a  blow  upon  one  of  the  bones  forces  it  directly 
away  from  the  other ;  or  it  may  be  indirect,  as  when  a  blow 
at  a  distant  part  of  a  bone  transmits  force  to  its  end  and 
drives  the  bone  out  of  its  socket.  Muscular  action  is  a 
cause  when  sudden  and  violent  muscular  contraction  occurs 
during  the  existence  of  a  position  of  the  joint  which  gives 
the  muscles  full  sway,  and  throws  the  head  of  the  bone 
against  the  weakest  part  of  its  retaining  ligaments. 

Pathological  Conditions. — In  a  recent  complete  traumatic 
dislocation  the  ligaments  are  damaged,  and  may  perhaps 
show  extensive  laceration,  or  may  show  only  a  button-hole 
laceration  through  which  a  bone  projects.  External  force 
produces  much  laceration  and  little  stretching  of  the  liga- 
ments ;  muscular  action  produces  little  laceration  and  much 
stretching  of  the  ligaments  (Mears).  In  some  cases  of  dis- 
location due  to  external  violence  the  structures  about  the 
joint  are  bruised  or  otherwise  damaged ;  the  old  socket  is 
filled  with  blood,  and  the  bone  in  its  new  situation  lies  in 
a  bloody  area.  Large  vessels  and  nerves  are  rarely  torn, 
though  they  may  be  compressed. 

If  a  dislocation  is  not  soon  reduced,  inflammation  arises 
in  the  old  joint  and  about  the  displaced  bone,  and  the  whole 
area  is  glued  together,  first  by  coagulated  exudate,  and  next 
by  embryonic  tissue.  After  a  time,  in  ball-and-socket  joints, 
the  old  socket  fills  with  fibrous  tissue,  contracts,  becomes 
irregular,  and  may  even  be  obliterated ;  the  head  of  the  dis- 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      433- 

located  bone  alters  its  shape,  its  cartilage  is  destroyed  or 
converted  into  fibrous  tissue,  and  the  pressure  of  the  head 
of  the  bone  forms  a  hollow  in  its  new  situation,  which  hol- 
low becomes  surrounded  by  fibrous  tissue  or  even  by  bone. 
A  new  joint  mav  form,  the  surrounding  tissue  becoming  a 
compact  capsule,  and  a  bursa  forming  between  the  head  of 
the  bone  and  its  new  socket.  In  a  dislocated  hinge-joint 
the  ends  of  the  bone  alter  greatly  in  shape  and  their  carti- 
lage is  converted  into  fibrous  tissue.  In  an  unreduced  dislo- 
cation the  muscles  shorten  or  lengthen  or  undergo  atrophy 
or  fatty  degeneration,  as  the  case  may  be.  An  unreduced 
dislocation  of  a  ball-and-socket  joint  may  give  a  fairly  mov- 
able new  joint,  but  an  unreduced  dislocation  of  a  hinge- 
joint  rarely  allows  of  much  motion. 

General  Symptoms  of  Traumatic  Dislocatiojis. — In  general, 
traumatic  dislocations  are  indicated  (i)  by  pain  of  a  sicken- 
ing, nauseating  character ;  (2)  by  rigidity  (voluntary  motion 
is  impossible  except  to  a  slight  extent  in  the  direction  of  the 
deformity.  For  instance,  in  dislocation  of  the  inferior  max- 
illary the  jaw  can  be  opened  a  little  more,  but  it  cannot  be 
closed.  This  rigidity  brings  about  loss  of  function.  When 
the  surgeon  attempts  to  move  the  joint  he  finds  it  very 
r'S'<^) '  (3)  by  change  in  the  shape  of  the  joint  (as  flattening 
of  the  shoulder  after  dislocation  of  the  humerus) ;  (4)  by 
alteration  in  the  mutual  relations  of  bony  prominences  about 
a  joint  (alteration  of  the  relation  between  the  olecranon  and 
humeral  condyles  in  dislocation  of  the  elbow  backward); 
(5)  by  feeling  the  displaced  bone  in  its  new  situation;  (6)  by 
missing  the  head  of  the  bone  from  its  proper  situation ;  (7) 
by  alteration  in  the  length  of  the  limb  (in  dislocation  of  the 
femur  into  the  thyroid  foramen  the  leg  is  lengthened,  but 
in  dislocation  into  the  dorsum  of  the  ilium  it  is  shortened); 
and  (8)  by  alteration  in  the  axis  of  the  bone  (in  dislocation 
upon  the  dorsum  of  the  ilium  the  axis  of  the  injured  thigh 

28 


•434  ^    MANUAL    OF  SURGERY. 

would,  if  prolonged,  pass  through  the  lower  third  of  the 
sound  thigh). 

Diagnosis  of  Traumatic  Dislocation. — A  dislocation  may 
be  mistaken  for  a  fracture.  In  dislocation  there  is  rigidity, 
in  fracture  there  is  preternatural  mobility  ;  in  dislocation  there 
is  no  true  crepitus  (may  get  tendon-  or  joint-crepitus),  in  frac- 
ture there  usually  is  crepitus  ;  in  dislocation  the  deformity 
does  not  tend  to  recur  after  reduction,  in  fracture  it  does 
recur  after  extension  is  relaxed.  In  a  sprain  the  movements 
of  the  joint  are  only  limited,  not  abolished  by  an  almost  com- 
plete rigidity.  The  change  which  a  sprain  may  cause  in  the 
shape  of  a  joint  is  due  to  effusion  or  to  bleeding ;  there  is 
no  alteration  in  the  relation  of  the  bony  prominences  to  one 
another;  there  is  no  notable  alteration  in  the  length  of  the 
limb  (a  slight  increase  in  length  may  arise  from  joint-effusion, 
or  the  head  of  the  bone  may  subsequently  be  absorbed,  and 
thus  produce  shortening  after  some  weeks) ;  there  is  no 
alteration  in  the  axis  of  the  bone ;  the  head  is  not  felt  in 
a  new  position,  it  being  found  in  its  normal  place.  Always 
remember  that  a  fracture  may  exist  with  a  dislocation.  In 
any  doubtful  case — in  fact,  in  most  cases — giv^e  ether,  for  a 
dislocation  should  be  reduced  while  the  patient  is  anaesthe- 
tized (except  in  dislocation  of  the  jaw,  of  the  fingers,  of  the 
carpus,  etc.).  In  some  cases  swelling  renders  the  diagnosis 
difficult  or  impossible.  Always  compare  the  injured  joint 
with  the  corresponding  joint  of  the  sound  side. 

Treatment  of  Traumatic  Dislocations :  Recent  Simple  Dis- 
locations.— Reduce  simple  dislocations  under  ether,  as  a  rule. 
Try  manipulation^  a  procedure  in  which  it  is  sought  to  make 
the  bone  retrace  its  own  pathway.  If  this  procedure  fails, 
employ  extension  and  counter-extension.  If  considerable 
force  is  needed,  an  assistant  makes  counter-extension,  and 
the  surgeon  fastens  to  the  extremity  a  clove-hitch  which  he 
ties  about  his  waist,  and  thus  secures  powerful  extension. 


DISEASES  AND   EV/ CAVES   OF  BONES  AND  JOEXTS.      435 

Counter-extension  may  be  obtained  by  bands  or,  in  some 
instances,  by  the  foot  of  the  surgeon.  The  clove-hitch  is 
used  because  it  will  not  tighten  by  traction,  as  a  tighten- 
ing band  would  lacerate  the  soft  parts  (Fig.  68).  If  great 
power  is  needed,  compound  pulleys  may  be  employed,  such  as 
the  Jarvis  adjuster  or  some  similar  appliance  (see  pages  447, 
459).  If  these  means  fail,  cut  down  upon  the  bone  and  restore 
it  to  position.  After  reducing  a  dislocation,  immobilize  the 
joint  for  a  time  (time  varies  with  different  joints),  and  for  the 
first  few  days  combat  swelling  and  inflammation  with  evaporat- 
incT  lotions.  If  there  exists  a  fracture  of  the  dislocated  bone, 
apply  splints  and  then  try  to  reduce  by  manipulations, 
grasping  the  limb  and  the  splint  with  one  hand  below 
and,  if  possible,  with  the  other  hand  above  the  seat  of  the 
fracture.  In  some  cases  with  fracture  reduction  can  be 
much  aided  by  screwing  a  gimlet  into  the  head  of  the  bone 
and  using  this  tool  as  a  handle.  If  the  fracture  is  near  the 
joint  and  the  fragments  cannot  be  fixed,  try  to  reduce  the 
dislocation,  first  striving  to  press  the  bone  into  place. 

Compound  Traumatic  Dislocations. — The  opening  in 
the  soft  parts  may  be  due  to  external  violence  or  to  projec- 
tion of  a  bone.  Compound  dislocations  are  very  serious. 
Hinge-joints  are  more  often  victims  to  these  injuries  than 
are  ball-and-socket  joints.  Many  cases  require  excision  and 
amputation  ;  all  that  do  not  demand  excision  or  amputation 
are  treated  by  counter-opening,  by  careful  antisepsis,  by 
drainage,  and  by  immobilization,  ankylosis  generally  ensu- 
ing, except  sometimes  in  the  small  joints.  It  is  scarcely  ever 
necessary  to  cut  away  any  portion  of  the  protruding  bone 
to  effect  reduction.  If  a  joint  is  badly  splintered  or  if  the 
soft  parts  are  extensively  damaged,  excise  or  amputate ;  if 
the  main  vessels  or  the  nerves  are  seriously  injured,  or  if  the 
patient  is  so  old  or  so  feeble  that  it  is  perilous  to  force  him 
to  combat  a  long  illness,  then  amputate. 


43^  A    MANUAL    OF  SfA'OFA'V. 

Old  Traumatic  Dislocations. — The  problem  always  pre- 
sented in  old  dislocations  is,  Shall  reduction  be  tried,  or 
shall  the  bones  be  left  alone?  Sir  Astley  Cooper  laid  down 
this  rule  :  "  Do  not  attempt  to  reduce  a  shoulder-dislocation 
after  three  months,  nor  a  hip-dislocation  after  two  months;" 
but  this  rule  was  laid  down  before  the  days  of  ether.  Do 
not  select  any  fixed  period  of  time  to  determine  the  action. 
In  dislocation  of  a  ball-and-socket  joint  considerable  motion 
may  become  possible  and  a  new  joint  may  form.  If  move- 
ment does  not  produce  pain,  a  good  new  joint  may  eventu- 
ally be  obtained  by  faithful  passive  movements  ;  if  movement 
of  the  limb  does  produce  pain,  enough  motion  will  not  be 
attempted  by  the  patient  to  produce  a  useful  joint.  In  the 
former  case  try  to  obtain  a  useful  new  joint,  and  in  the  latter 
case  try  to  reduce  the  old  dislocation. 

In  trying  to  reduce  an  old  dislocation,  give  ether,  make 
movements  to  break  up  adhesions,  and  persist  in  making 
these  motions  until  the  head  of  the  bone  is  felt  to  move ; 
then  try  at  once  to  reduce  by  manipulation,  extension,  or 
the  pulleys,  not  waiting  for  two  days,  as  some  suggest.  If 
the  head  of  the  bone  cannot  be  made  to  move,  there  may  be 
followed  the  Dieffenbach  plan,  which  is  to  cut  the  tense 
restraining  bands  with  a  tenotome.  Always  remember  that 
dislocations  of  a  hinge-joint,  if  left  unreduced,  will  never 
eventuate  in  a  useful  artificial  joint.  Sir  Joseph  Lister,  being 
much  impressed  with  the  danger  inevitably  linked  with  for- 
cibly dragging  old  dislocations  into  place,  prefers  to  cut 
down  and  restore  the  bone,  employing,  of  course,  the  fullest 
antisepsis. 

Special  Traumatic  Dislocations  :  Lower  Jaw, — With- 
out fracture  the  lower  jaw  can  only  be  dislocated  forward. 
There  are  two  forms  of  dislocation — the  itnilatcral,  which  is 
rare,  and  the  bilattval,  which  is  common.  Dislocations  of 
the  jaw  are  commonest  in  women  and  during  middle  life. 


DISEASES  AND   IXJURIES   Of  BONES   AND  JOINTS.      437 

When  the  mouth  is  open  contraction  of  the  external  ptery- 
goid can  pull  the  condyle  over  the  articular  eminence ;  this 
contraction  may  be  brought  about  by  yawning,  vomiting, 
scolding,  etc.  When  the  mouth  is  open  dislocation  of  the 
lower  jaw  can  be  caused  by  a  blow  upon  the  chin  ;  it  can 
also  be  caused  by  forcing  the  mouth  more  widely  open  by 
pushing  a  bulky  body  between  the  teeth. 

Syiiipfoius  of  Loivcv-jaw  Dislocations. — In  the  bilateral 
form  the  mouth  is  open  and  fixed,  and  it  cannot  be  closed, 
though  it  can  be  opened  a  little  more.  The  condyles  are 
in  front  of  the  articular  eminences,  and  are  fixed  by  the 
action  of  the  masseters  and  internal  pterygoids,  the  coronoid 
processes  being  wedged  against  the  malar  bones.  The  lower 
jaw^  is  advanced  in  front  of  the  upper  and  the  face  looks 
longer  than  natural.  The  lips  cannot  close,  the  saliva  ov^er- 
flows,  swallowing  and  speech  are  difficult,  there  is  a  depres- 
sion in  front  of  the  ear,  the  condyle  is  recognizable  in  its 
new  abode,  the  coronoid  process  is  detected  by  a  finger  in  the 
mouth,  and  the  masseters  and  temporals  stand  out  in  a  state 
of  rigidity.  Pain  may  be  severe  or  be  absent.  In  the  21m- 
latcral  form  the  chin  goes  toward  the  sound  side,  and  the 
mouth  is  not  so  widely  open  as  in  the  bilateral  form,  neither 
is  the  jaw  so  fixed.  The  symptoms  are  similar  to  those  of 
a  bilateral  luxation,  but  are  not  so  pronounced.  The  hollow 
in  front  of  the  ear  and  the  condyle  in  an  abnormal  situation 
are  only  detected  upon  one  side.  In  an  unreduced  disloca- 
tion the  patient  may  after  a  time  establish  some  movement 
of  the  jaw,  but  the  power  of  mastication  will  always  be  im- 
paired seriously. 

Treatment  of  Loiver-jaw  Dislocations. — In  treating  dislo- 
cations of  the  lower  jaw  the  patient  is  placed  with  his  head 
against  the  back  of  a  chair  or  against  the  body  of  an  assist- 
ant. The  surgeon,  after  wrapping  up  his  thumbs  to  save 
them  from  being  bitten,  stands  in  front  of  the  patient,  puts 


438  A   MANUAL    OF  SURGERY. 

his  thumbs  upon  the  last  molar  teeth,  and  grasps  the  chin 
with  his  free  fini^crs.  He  now  presses  downward  and  back- 
ward on  the  jaw,  and  as  soon  as  the  condyle  is  loosened 
closes  the  jaw  over  the  condyle  by  pushing  up  the  chin, 
using  his  thumbs  as  levers.  If  this  procedure  fails,  wedges 
should  be  put  between  the  molar  teeth  and  the  chin  should 
be  pushed  up  either  by  the  hands  or  by  a  tourniquet  whose 
band  is  round  the  head  and  chin.  In  a  unilateral  disloca- 
tion the  wedge  should  only  be  used  on  the  injured  side. 
In  difficult  cases  Sir  Astley  Cooper  took  a  round  wooden 
ruler  and  pushed  it  between  the  molar  teeth,  using  the  upper 
teeth  as  a  fulcrum  and  raising  the  end  of  the  ruler  as  the 
handle  of  a  lever.  The  forceps  used  by  an  anaesthetizer  may 
depress  the  condyle  from  its  point  of  fixation,  whereupon 
the  chin  may  be  pushed  up  and  back.  Nelaton's  plan  was 
to  put  the  thumbs  in  the  mouth  and  push  the  coronoid  pro- 
cesses backward.  In  an  old  dislocation  always  try  reduc- 
tion, at  least  up  to  a  period  of  six  or  seven  months.  After 
reduction  apply  a  Barton  bandage  for  over  two  weeks,  taking 
it  off  once  a  day,  and  begin  passive  motion  in  the  second 
week ;  discard  the  bandage  in  the  third  week.  Liquid  diet 
is  advisable  for  three  weeks  after  the  accident. 

Dislocation  of  the  Clavicle :  Sternal  End. — There  are 
three  forms  of  dislocation  of  the  sternal  end  of  the  clavicle, 
namely:    (i)  forward;    (2)  backward;    and  (3)  upward. 

Forward  Dislocation  of  the  Clavicle. — The  causes  of 
forward  dislocation  of  the  clavicle  are  blows,  falls,  or  pulls 
which  drive  or  draw  the  shoulder  backward. 

Symptoms  and  Treatment  of  Dislocation  of  the  Clavicle. — 
The  symptoms  manifest  in  dislocation  of  the  clavicle  are 
— prominence  in  front  of  the  sternum  ;  the  acromion  is  nearer 
to  the  sternum  on  the  injured  than  on  the  sound  side;  the 
clavicular  origin  of  the  sterno-cleido-mastoid  is  rigid;  move- 
ment is  difficult  and  painful.     To  treat  a  dislocation  of  the 


DISEASES  AND    INJURIES   OF  BONES  AND  JOINTS.      439 

clavicle,  pull  the  shoulders  back  against  the  knee  placed 
between  the  scapulae.  Dress  with  a  posterior  figure-of-8 
bandage  (PI.  12,  Fig.  5)  or  a  Velpeau  bandage  (PI.  13,  Fig.  4), 
the  dressing  to  be  worn  for  three  weeks.  After  removal  of 
the  dressing  apply  a  truss  the  pad  of  which  is  put  over  the 
head  of  the  clavicle,  and  which  instrument  is  to  be  worn 
for  a  month.  Dislocation  of  the  clavicle  is  difficult  to  keep 
reduced,  but  even  if  it  becomes  fixed  in  deformity  the 
motions  of  the  arm   will  not  be   impaired  permanently. 

Backward  dislocation  of  the  clavicle  is  very  rare.  The 
causes  are  direct  violence  and  indirect  force,  such  as  falls  or 
blows  which  drive  the  shoulder  forward  and  inward. 

Symptoms  and  Treatment  of  Backward  Dislocation  of  the 
Clavicle. — The  symptoms  are — pain  ;  loss  of  function  in  the 
arm  ;  inclination  of  head  toward  the  injured  side  ;  stiffness  of 
the  neck  ;  the  shoulder  passes  forward  and  inward,  and  often 
falls  downward  ;  a  depression  exists  over  the  sterno-clavicular 
joint;  the  head  of  the  clavicle  cannot  be  felt,  or  is  found 
back  of  the  sternum.  The  displaced  clavicle  may  press 
upon  the  trachea,  the  oesophagus,  or  the  great  vessels, 
inducing  dyspnoea,  dysphagia,  obliteration  of  pulse  in  the 
arm  of  the  injured  side,  or  great  venous  congestion  of  the 
head  (see  Pick).  To  treat  a  backward  dislocation,  pull  the 
shoulders  backward  and  apply  a  posterior  figure-of-8  band- 
age (PI.  12,  Fig.  5),  which  must  be  worn  for  three  weeks. 
If  pressure-symptoms  are  urgent,  resect  the  displaced  head. 

Upward  dislocation  of  the  clavicle  is  very  rare.  The 
cause  is  indirect  force  which  carries  the  shoulder  downward, 
inward,  and  backward  (Smith). 

Symptoms  and  Treatment  of  Upward  Dislocation  of  the 
Clavicle. — The  chief  symptom  is  impaired  function  of  the 
arm ;  the  shoulder  passes  downward  and  inward,  the  clavic- 
ular axis  is  altered,  and  the  displaced  head  is  felt.  Dyspnoea 
may  or  may  not  exist.     To  treat  this  dislocation,  put  a  pad 


440  A   MANUAL    OF  SURGERY. 

in  the  axilla  and  press  the  elbow  to  the  side  in  order  to 
throw  the  bone  outward,  and  try  to  push  the  head  into 
place.  Apply  a  Desault  bandage  (PI.  13,  Figs.  1-3)  and  place 
a  firm  pad  over  the  sterno-clavicular  joint.  The  deformity  is 
apt  to  recur,  but  a  useful  limb  will  nevertheless  be  obtained. 

Dislocation  of  the  acromial  end  of  the  clavicle  is 
almost  always  upward,  but  it  may  be  below  the  acromion. 
The  cause  is  violent  force,  which,  if  so  applied  to  the  scapula 
as  to  drive  the  shoulder  forward,  may  produce  a  dislocation 
upward.  A  dislocation  downward  is  due  to  blows  upon  the 
upper  surface  of  the  outer  end  of  the  clavicle. 

Symptoms  and  Treatment. — The  symptoms  of  dislocation 
of  the  acromial  end  of  the  clavicle  are — prominence  of  the 
clavicle  upon  the  top  of  the  acromion  ;  impaired  function 
of  the  arm  (cannot  be  lifted  over  the  head) ;  the  shoulder 
falls  downward  and  passes  inward  ;  there  is  apparent  length- 
ening of  the  arm  ;  the  head  is  bent  toward  the  injured  side, 
and  the  clavicular  origin  of  the  trapezius  is  strongly  out- 
lined (Pick).  In  dislocation  downward  both  the  acromion 
and  the  coracoid  are  very  prominent,  the  clavicular  axis  is 
altered,  and  there  is  depression  over  the  sterno-clavicular 
joint.  A  dislocation  upward  is  reduced  by  pulling  the 
shoulder  back  and  pushing  the  bone  into  place.  Apply  a 
Desault  bandage,  which  must  be  kept  on  for  three  weeks. 
More  or  less  deformity  is  inevitable.  Dislocation  downward 
is  reduced  and  treated  the  same  as  dislocation  upward. 

Dislocation  of  the  lo"wer  angle  of  the  scapula  is  not, 
as  it  was  long  thought  to  be,  a  dislocation  at  all.  The 
lower  angle  and  vertebral  border  deviate  from  the  chest. 
This  condition  was  thought  to  be  due  to  the  bone  slip- 
ping from  under  the  latissimus  dorsi  muscle,  but  it  is  now 
known  to  be  due  to  paralysis  of  the  serratus  magnus  muscle, 
the  bone  being  acted  upon  by  the  trapezius,  pectoralis  minor, 
levator  anguli  scapulae,  and  rhomboid  muscles.     Examina- 


DISEASES  AXD   LVJURIES   OF  BOXES  AXD  JOIXTS.      44 1 

tion  shows  that  the  scapula  will  not  rotate  normally  forward. 
This  is  demonstrated  by  extending  the  arms  in  front  to  a 
right  angle,  the  gliding  forward  of  the  scapula  upon  the 
sound  side  being  marked  and  upon  the  diseased  side  being 
slight  or  absent. 

Treatment  of  dislocation  of  the  lower  angle  of  the  scapula 
comprises  massage,  electricity,  passive  motion,  and  deep  in- 
jections of  strychnine. 

Dislocations  of  the  Humerus  (Shoulder-joint). — These 
injuries  are  most  frequent  because  of  the  free  mobility  of  the 
shoulder-joint,  its  anatomical  insecurity,  and  its  exposed 
situation.  These  dislocations  are  rare  in  the  very  young 
and  in  the  aged,  being  oftenest  encountered  in  muscular 
young  adults.  Four  forms  of  shoulder-joint  dislocation 
exist,  namely:  (i)  forward,  inward,  and  downward,  under 
the  coracoid  process — subcoracoid  ;  (2)  downward,  forward, 
and  inward,  beneath  the  glenoid  cavity — subglenoid ;  (3) 
backward,  inward,  and  downward,  under  the  spine  of  the 
scapula — subspinous  ;  and  (4)  forward,  inward,  and  upward, 
under  the  clavicle — subclavicular. 

A  very  rare  form  of  shoulder-joint  dislocation  has  been 
described,  which  is  known  as  the  "  supracoracoid." 

Subcoracoid  Luxation. — The  subcoracoid  variety  of  dislo- 
cation embraces  three-fourths  of  all  the  shoulder-joint  luxa- 
tions. It  may  be  caused  by  direct  force  driving  the  head  of 
the  humerus  forward  and  inward,  or  by  indirect  force,  such 
as  falls  upon  the  hand  or  the  elbow.  In  this  dislocation  the 
anatomical  neck  of  the  humerus  lies  upon  the  anterior 
margin  of  the  glenoid  cavity,  just  beneath  the  coracoid 
process,  and  is  above  the  tendon  of  the  subscapularis  muscle. 

Subglenoid  or  axillary  luxation  may  be  produced  by  con- 
traction of  the  great  pectoral  and  latassimus  dorsi  muscles 
when  the  arm  is  at  a  right  angle  to  the  body,  but  it  is  usually 
due  to  falls  upon  the  hand  or  the  elbow  when  the  arm  is 


442  A   MANUAL    OF  SURGERY. 

raised  and  the  head  of  the  bone  is  against  the  lower  portion 
of  the  capsule.  In  this  dislocation  the  head  of  the  bone 
rests  upon  the  border  of  the  scapula,  below  the  tendon  of 
the  subscapularis,  in  front  of  the  long  head  of  the  triceps, 
and  above  the  teres  muscles.  Some  observers  hold  that 
most  dislocations  of  the  shoulder  are  prin^arily  subglenoid, 
the  position  having  been  altered  by  muscular  action. 

Subspinous  luxation  is  a  rare  injury.  Pick  met  with  this 
accident  in  a  man  who,  while  having  his  hands  in  his  pockets, 
fell  upon  the  front  of  the  point  of  the  shoulder.  The  head 
of  the  bone  reposes  beneath  the  scapular  spine,  between  the 
infraspinatus  and  teres  minor  muscles. 

Subclavicular  luxation  is  very  rare.  It  is  caused  by  the 
same  sort  of  violence  which  produces  subcoracoid  luxation. 
The  head  of  the  bone  rests  upon  the  thorax,  below  the 
clavicle  and  underneath  the  pectoralis  major  muscle. 

In  the  rare  form  known  as  the  "  supracoracoid  "  the  head 
of  the  humerus  rests  upon  the  coraco-acromial  ligament  or 
upon  the  acromion  process.  The  acromion  or  the  coracoid 
is  always  fractured. 

Symptoms  of  Dislocation  of  the  Shoulder-joint. — Disloca- 
tion is  diagnosticated  by  (i)  pain  of  a  sickening  character; 
(2)  flattening  of  the  shoulder,  the  head  of  the  bone  having 
ceased  to  bulge  out  the  deltoid  muscle  ;  (3)  apparent  projec- 
tion of  the  acromion  through  sinking  in  of  the  deltoid ;  (4) 
hollow  beneath  the  acromion,  over  the  empty  glenoid  cavity, 
and  the  bone  missed  from  its  normal  habitat;  (5)  rigidity 
(some  movement  is  possible,  in  the  direction  especially  of 
an  existing  deformity,  but  mobility  is  strictly  limited  and 
attempts  at  motion  produce  great  pain) ;  (6)  the  elbow  can- 
not touch  the  side  when  the  hand  is  placed  upon  the  sound 
shoulder — Dugas's  sign  (this  is  due  to  the  rotundity  of  the 
chest.  In  a  dislocation  the  head  of  the  bone  is  already 
touching   the    chest,    and   the    bone,    being   approximately 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      443 

straight,  cannot  touch  it  in  two  places  at  the  same  time.  If 
the  elbow  can  be  placed  against  the  chest  with  the  hand  on 
the  sound  shoulder,  there  can  be  no  dislocation ;  if  it  cannot 
be  so  placed,  there  must  be  dislocation) ;  and  (7)  finding  the 
head  of  the  bone  in  a  new  situation.  Symptoms  i  to  5  may 
be  grouped  as  Erichsen's  list  of  signs.  The  form  of  disloca- 
tion is  made  out  by  a  study  of  the  direction  of  the.  axis  of 
the  limb,  the  existence  and  extent  of  lengthening  or  of 
shortening,  and  the  situation  of  the  head  of  the  bone. 

The  following    table  from  T.  Pickering   Pick's  work    on 
Fractures  and  Dislocations  makes  the  above  points  clear  : 


Subcoracoid. 


Subglenoid. 


Subspinous. 


Subclavicular. 


Direction  of  the 
Axis  of  the  Limb. 


Alteration  in  the 
Length  of  the  Limb. 


The  elbow  is  car-        Very     slight 
ried  backward  and  |  lengthening, 
slightly  away  from 
the  side. 

The  elbow  is  car-        Very    consider- 
ried  away  from  the  ,  able  lengthening, 
trunk    and   slightly 
backward. 

The  elbow  is 
raised  from  the  side 
and  carried  for- 
ward. 

The  elbow  is  car- 
ried outward  and 
backward. 


Lengthening  in- 
termediate in  de- 
gree between  the 
subglenoid  and  the 
subcoracoid. 

Shortening. 


Presence  of  the  Head 
of  the  Bone  in  New 
Situation. 


The  head  of  the 
bone  cannot  easily  be 
felt ;  if  it  can,  it  is 
found  at  the  upper  and 
inner  part  of  the  axilla. 

The  head  of  the 
bone  can  easily  be  felt 
in  the  axilla. 

The  head  of  the 
bone  can  be  felt  and  be 
grasped  beneath  the 
spine  of  the  scapula. 

The  head  of  the 
bone  can  readily  be 
seen  and  be  felt  be- 
neath the  clavicle. 


In  a  shoulder-joint  dislocation  the  head  of  the  bone  may 
press  upon  the  brachial  plexus  and  produce  pain  and  numb- 
ness, and  sometimes  a  traumatic  neuritis  or  paralysis ;  some- 
times pressure  upon  the  axillar\'  vein  causes  intense  oedema, 
and  pressure  upon  the  axillary  arter\'  diminishes  or  obliter- 
ates the  pulse.  The  axillary  vessels  ma}-  be  torn  and  the 
muscles  may  be  lacerated  badl\-.     The  capsule  is  torn  and 


444  ^   MANUAL    OF  SURGERY. 

considerable  blood  is  usually  effused.  Swelling  is  due  first 
to  hemorrhage  and  secondly  to  inflammation.  Partial  dis- 
locations sometimes,  though  rarely,  occur.  What  is  usually 
spoken  of  as  "  partial  dislocation  "  is  a  condition  in  which 
the  head  of  the  humerus  passes  forward  under  the  coracoid 
because  of  rupture  of  the  long  head  of  the  biceps  or  because 
this  tendon  slips  out  of  its  groove,  the  ligaments  being  intact. 

Diagnosis  of  Shoiildcr-joint  Dislocation. — In  fracture  of  the 
neck  of  the  scapula  there  is  prominence  of  the  acromion  and 
a  hollow  below  it,  a  hard  body  being  felt  in  the  axilla;  but 
the  coracoid  process  descends  with  the  head  of  the  bone, 
which  it  does  not  do  in  dislocation.  Furthermore,  in  frac- 
ture there  is  rigidity ;  in  dislocation  mobility.  In  fracture 
crepitus  is  present ;  in  dislocation  it  is  absent.  In  fracture 
the  deformity  is  easily  reduced,  but  it  at  once  recurs ;  in  dis- 
location the  deformity  is  with  difficulty  reduced,  but  does 
not  recur.  In  fracture  the  elbow  can  be  made  to  touch  the 
side  when  the  hand  is  upon  the  sound  shoulder;  in  disloca- 
tion it  cannot  be  so  manipulated.  In  fracture  of  the  anatomi- 
cal neck  of  the  humerus  deformity  is  slight;  the  head  of  the 
humerus  is  found  in  place,  and  does  not  move  when  the  shaft 
is  rotated  ;  and  the  head  is  not  in  line  with  the  axis  of  the 
bone.  Crepitus  exists  in  fracture  if  impaction  is  absent.  In 
paralysis  of  the  deltoid  there  is  distinct  flattening,  but  the 
bone  is  felt  in  place  and  there  is  no  rigidity. 

Treatment  of  SJioiilderfoint  Dislocation. — Reduction  by 
manipulation  is  usually  readily  obtained  in  recent  cases  of 
shoulder-joint  dislocation.  Always  give  ether.  Forward  dis- 
locations (subcoracoid,  subclavicular,  and  axillary)  are  re- 
duced by  Kocher's  method  (Fig.  73) :  Put  the  arm  against  the 
side,  flex  the  forearm  to  a  right  angle  with  the  arm,  perform 
external  rotation  of  the  arm  until  the  forearm  is  at  a  right 
angle  with  the  body,  raise  the  elbow,  make  internal  rotation, 
and  place  the  hand  on  the  opposite  shoulder.     The  formula 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      445 

is,  flexion  of  the  forearm,  external  rotation,  abduction,  and 
internal  circumduction  of  the  arm.  If  in  trying  Kocher's 
plan  external  rotation  of  the  humerus  does  not  take  place, 
abandon  the  method.  Another  method  of  manipulation  is  as 
follows  :  If  the  riglit  shoulder  is  dislocated,  the  surgeon  stands 
behind  the  patient  (whose  shoulders  are  raised);  if  the  left 
shoulder  is  dislocated,  he  stands  in  front  of  the  patient. 
The  surgeon  holds  the  arm  flexed  upon  the  forearm  with 
his  right  hand  and  makes  external  traction  and  rotation,  and 
with  the  fingers  of  his  left  hand  he  tries  to  force  the  bone 
into  place. 

In  Henry  H.  Smith's  method  for  forward  dislocations  the 
surgeon  stands  in  front  of  the  patient.  If  the  left  shoulder 
is  dislocated,  the  surgeon  grasps  it  with  his  left  hand ;  if  the 
right  shoulder  is  dislocated,  he  grasps  it  with  his  right 
hand,  the  thumb  resting  on  the  head  of  the  bone.  With  his 
disengaged  hand  the  surgeon  grasps  the  elbow,  abducts  it, 
makes  traction  and  external  rotation,  and  suddenly  sweeps 
the  elbow  inward,  aiming  it  at  the  sternum,  and  tries  with  his 
thumb  to  push  the  bone  into  place.  In  subspinous  luxations 
the  surgeon  stands  behind  the  patient,  makes  abduction, 
traction,  and  internal  rotation,  sweeps  the  elbow  inward 
toward  the  spine,  and  with  the  thumb  aids  the  bone  in  its 
return  into  position.  Raising  the  elbow  far  above  the  head 
and  sweeping  it  inward  will  reduce  some  dislocations.  As 
the  head  of  the  bone  slips  back  a  distinct  jar  is  felt  and  a 
snap  is  heard,  the  motions  o^  the  joint  are  again  obtainable, 
and  with  the  hand  on  the  opposite  shoulder  the  elbow  may 
be  made  to  touch  the  side. 

Reduction  by  Extension. — In  reduction  of  shoulder-joint 
dislocation  by  extension  the  patient  is  anaesthetized  and 
placed  upon  a  low  bed  or  upon  the  floor.  The  surgeon 
then  places iiis  foot,  co\ered  only  by  a  stocking,  in  the  axilla. 
Place  the  sole  of  the  foot,  not  the   heel,  against  the  chest 


446  A   MANUAL    OF  SURGERY. 

high  up,  the  instep  being  made  to  touch  the  humerus  and 
the  heel  the  border  of  the  shoulder-blade,  a  towel  being 
first  put  into  the  axilla  to  rest  the  foot  against  (Fig.  70).  If 
the  left  arm  is  dislocated,  use  the  left  foot,  or  vice  versa. 
The  elder  Gross  approved  of  sitting  between  the  patient's 
limbs.  Make  steady  extension,  which  will  in  many  cases 
bring  about  the  reduction.  If  it  fails  to  cause  reduction, 
bring  the  patient's  arm  across  the  chest  and  use  the  foot  as 
the  fulcrum  of  a  lever.  If  the  humerus  is  pretty  firmly  fixed 
in  its  abnormal  position,  make  counter-extension  with  a  foot 
in  the  axilla  and  make  extension  by  fixing  a  clove-hitch 
(Fig.  68)  above  the  elbow  and  fastening  to  it  bands  which 
go  over  one  shoulder  and  under  the  other  shoulder  of  the 
surgeon.  The  back  may  be  used  for  extension,  the  hands 
being  left  free  for  manipulation  (Allis's  and   Pick's  plan). 

The  late  Prof  Pancoast  favored  Sir  Astley  Cooper's 
method  of  placing  the  unanaesthetized  patient  in  a  chair  and 
using  the  knee  as  a  fulcrum,  pushing  the  elbow  to  the  side 
(Fig.  69).  A  good  method  is  that  in  which  the  surgeon  stands 
behind  the  patient,  steadies  the  scapula  with  his  foot  or  hand, 
and  carries  the  patient's  arm  above  his  head,  making  exten- 
sion and  external  rotation  (Fig.  71).  Cock  advises,  when 
reduction  fails,  that  an  air-pad  be  placed  in  the  axilla  and 
the  arm  be  bound  to  the  side — a  method  by  which  reduction 
will  often  take  place  after  two  or  three  days.  The  pulleys 
are  very  rarely  used,  as  they  develop  a  dangerous  force, 
antiseptic  incision  being  a  safer  and  a  better  expedient. 
If  the  pulleys  are  used,  break  up  adhesions  by  repeated  and 
forcible  movements  ;  fix  the  scapula  by  a  collar  and  band 
fastened  to  the  wall ;  attach  the  pulleys  by  one  end  to  a 
clove-hitch  fastened  above  the  elbow,  and  by  the  other  end 
to  the  wall ;  extension  is  made  until  the  head  of  the  bone 
moves,  whereupon  attempts  are  made  to  push  and  manipu- 
late it  into  the  glenoid  cavity  (Fig.  72). 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS      447 
\1 


Fig.  68.— Clove-hitch  Knot  applied 
above  the  Wrist  (after  Erichsen). 


Fig.  70. — Reduction  of  Shoulder-joint  Dislo 
cation   by  the  Foot  in  the  A.xilla  (CooperJ. 


Fig. 69. — Reduction  of  Shoulder- 
joint  Dislocation  by  the  Knee  in 
the  Axilla  (Cooper). 


Fig.  71. — Reduction   of  Shoulder-joint   Dislo-        Fig.    72. — Reduction    of    Shoulder-joint 
cation  by  E.xtension  Upward  (Cooper).  Dislocation  by  the  Pulleys   (Cooper). 


Fig.  73. — Kocher's  Method  of  Reduction  by  Manipulation  (Ceppi)  :  A,  first  movement, 
outward  rotation  ;  B,  second  movement,  elevation  of  elbow  ;  c,  third  movement,  inward 
rotation  and  lowering  of  the  elbow. 


448  A   MANUAL    OF  SURGERY. 

In  reducing  a  dislocation  the  axillary  artery  or  vein  may 
be  ruptured,  fracture  of  the  neck  of  the  humerus  may  take 
place,  injury  to  the  brachial  artery  may  occur,  or  the  soft  parts 
may  be  badly  damaged.  After  reducing  a  dislocation,  apply 
a  Velpeau  bandage,  keep  the  shoulder  immobile  for  one  week, 
then  make  passive  motion  daily ;  the  patient  may  wear  a  sling 
alone,  during  the  third  week,  after  which  period  he  may  use 
the  arm.  (For  old  dislocations  and  compound  dislocations 
see  page  435).  Reduction  of  old  dislocations  may  some- 
times be  effected  by  manipulation.  Extension  may  have  to 
be  used,  and  ether  may  be  required.  In  old  dislocations 
try  to  reduce,  after  breaking  up  adhesions,  by  forced  flexion 
and  strong  extension.  After  reduction  immobilize  for  three 
weeks,  and  start  passive  motion  after  seven  days. 

Dislocations  of  the  Elbow-joint. — Injuries  of  the  elbow- 
joint  are  not  rare,  and  they  are  commonest  in  children. 
Both  bones  or  only  one  bone  may  be  dislocated,  and  the 
dislocation  may  be  partial  or  be  complete. 

Dislocation  of  Both  Bones  Backward. — The  causes  of 
backward  dislocation  of  both  bones  of  the  elbow-joint  are 
falls  upon  the  extended  hand  or  twists  inward  of  the  ulna 
(Malgaigne).  The  coronoid  process  lodges  in  the  olecranon 
fossa. 

Symptoms  of  Backward  Dislocation. — In  complete  dislo- 
cation of  both  bones  of  the  elbow-joint  the  olecranon  is 
very  prominent ;  the  distance  between  the  point  of  the  olec- 
ranon and  the  apex  of  the  inner  condyle  is  notably  greater 
than  on  the  sound  side ;  the  forearm  is  flexed,  supinated, 
and  shortened  ;  the  lower  end  of  the  humerus  projects  in 
front  of  the  joint,  below  the  skin-crease ;  the  head  of  the 
radius  is  found  back  of  the  outer  condyle ;  and  there  are 
the  general  symptoms  of  dislocation.  Fracture  of  the 
coronoid  rarely  occurs  Vv^ith  backward  dislocation,  but  if  it 
does  occur  there  will  be  crepitus  and  mobility.     In  fracture 


DISEASES  AND   EXJURIES   OF  BO.VES  AXD  JOEXTS.      449 

above  the  condyles  there  are  found  the  ordinary  symptoms 
of  a  fracture  ;  measurement  from  condyles  to  styloid  processes 
does  not  show  shortening ;  there  is  no  alteration  of  normal 
relation  between  olecranon  process  and  condyles  ;  and  the 
projection  in  front  of  the  joint  is  above  the  crease  of  the 
bend  of  the  elbow. 

Treatment  of  Backzuard  Dislocation. — Reduction  must  be 
made  early  in  dislocation  of  both  bones  of  the  elbow-joint, 
or  it  will  be  found  impossible,  and  an  unreduced  dislocation 
means  a  limb  without  the  powers  of  flexion,  pronation,  and 
supination.  The  surgeon  places  his  knee  in  front  of  the  el- 
bow-joint, grasps  the  patient's  wrist,  presses  upon  the  radius 
and  ulna  with  his  knee,  and  bends  the  forearm  with  consider- 
able force,  the  muscles  pulling  the  bones  into  place  (Sir  Astley 
Cooper's  plan).  Forced  flexion,  traction,  and  extension  may 
be  tried  (Fig.  74).  Apply  an  anterior  angular  splint,  and  have 
it  worn  for  two  weeks.    Make  passive  motion  after  a  few  days. 

Dislocation  of  Both  Bones  Forward. — The  cause  of  for- 
ward dislocation  of  both  bones  of  the  elbow-joint  is  a  blow 
on  the  olecranon  when  the  arm  is  flexed.  It  is  a  rare 
accident. 

Symptoms  and  Treatment. — The  symptoms  of  forward  dis- 
location of  both  bones  of  the  elbow-joint  are — forearm  is 
flexed  and  lengthened ;  some  slight  motion  is  possible ; 
olecranon  is  on  a  level  with  the  condyles  if  unfractured, 
hence  its  prominence  is  gone ;  the  humeral  condyles  are 
felt  posteriorly,  and  the  radius  and  ulna  are  felt  anteriorly. 
The  treatment  of  this  injury  is  the  same  as  that  for  disloca- 
tion backward.  Forced  flexion  and  pressure  may  be  em- 
ployed for  reduction. 

Lateral  dislocations  of  both  bones  of  the  elbow-joint 
are  usually  incomplete. 

Symptoms  and  Treatment  of  Oiitivard  Dislocation. — The 
symptoms    of  outward    dislocation    of   both    bones    of  the 

29 


450 


A   MANUAL    OF  SUKGERV. 


elbow-joint  are — forearm  is  flexed,  fixed,  and  pronated ; 
joint  is  widened ;  the  head  of  the  radius  projects  externally 
and  has  a  depression  above  it;  the  inner  condyle  projects 
internally  and  has  a  depression  below  it ;  the  olecranon  is 
nearer   than   normal   to  the  external   condyle   and    further 

than  normal  from  the 
internal  condyle.  Reduc- 
tion is  effected  by  exten- 
sion of  the  forearm  and 
pressure  upon  the  head 
of  the  radius.  Apply  an 
ascending  spiral  reverse 
bandage  of  the  forearm, 
a    figure-of-8    bandage   of 

Fig.  74. — Reduction  of  Elbow-joint  Dislocation  .     .  ... 

(Tiemann).  the  clbow-joint,  aud  a  sung. 

Make  passive  motion  after  a  {^w  days.  The  bandages  must 
be  worn  for  two  weeks. 

Symptoms  and  Treatment  of  Imvard  Dislocation. — In  dislo- 
cation inward  of  both  bones  of  the  elbow-joint  the  position 
of  the  forearm  is  the  same  as  that  in  dislocation  outward ; 
the  sigmoid  cavity  of  the  ulna  projects  internally,  and  the 
external  condyle  projects  externally.  The  treatment  of  this 
form  of  elbow-joint  dislocation  is  the  same  as  that  employed 
in  the  preceding  form. 

Dislocation  of  the  ulna  alone  is  very  rare,  and  can  only 
take  place  backward. 

Symptoms  and  Treatment. — Dislocation  of  the  ulna  alone 
is  indicated  by  the  forearm  being  flexed  and  pronated.  The 
head  of  the  radius  is  found  in  place,  and  the  olecranon  pro- 
jects posteriorly.  The  treatment  of  this  injury  is  the  same 
as  that  of  the  preceding  dislocation. 

Dislocations  of  the  Radius  For-ward. — Dislocation  of  the 
radius  forward  is  the  commonest  form.  This  injury  is  caused 
by  a  fall  upon  the  hand  with  the  forearm  in  pronation  and 


DISEASES  AND   INJURIES   OE  BONES  AND  JOINTS.      45  I 

extension,  or  is  produced  by  blows  on  the  back  of  the 
joint ;   forced  pronation  alone  will  not  cause  it. 

Symptoms  and  Treatment. — The  symptoms  in  dislocation 
of  the  radius  forward  are — forearm  midway  between  prona- 
tion and  supination,  and  semiflexed;  attempts  to  increase 
flexion  cause  the  radius  to  strike  against  the  humerus  with 
a  distinct  blow;  the  head  of  the  radius  is  felt  in  front  of  the 
outer  condyle  and  is  missed  from  its  proper  abode.  Reduc- 
tion is  effected  by  extension  and  manipulation.  A  splint  is 
used  as  in  dislocation  of  both  bones.  Deformity  is  apt  to 
recur  after  reduction,  because  of  rupture  of  the  orbicular 
ligament. 

Dislocation  of  the  radius  backward  is  caused  by  falls 
on  the  hand  or  by  blows  on  the  front  of  the  joint. 

Symptoms  and  Treatment. — Backward  dislocation  of  the 
radius  is  indicated  by  the  forearm  being  slightly  flexed 
and  fixed  in  pronation,  by  some  impairment  of  flexion  and 
extension,  and  by  the  radius  being  felt  behind  the  outer 
condyle.  The  treatment  in  this  injury  is  the  same  as  that 
given  in  the  preceding  dislocation. 

Dislocation  of  the  radius  outward  is  very  rare.  In 
this  injury  the  head  of  the  radius  is  distinctly  felt.  The 
treatment  is  the  same  as  that  of  the  above-mentioned  dis- 
locations. 

Subluxation  of  the  Head  of  the  Radius. — This  name  is 
given  to  an  injury  which  is  very  frequent  in  children  between 
two  and  four  years  of  age.  It  results  from  traction  upon  the 
hand  or  the  forearm,  and  often  arises  when  the  nurse  or  the 
mother  pulls  upon  a  child's  arm  to  save  it  from  a  fall  or  to 
lift  it  over  a  gutter.  Some  writers  hold  that  pronation  is  re- 
quired, as  well  as  extension,  to  produce  the  injury;  many 
surgeons  claim  that  extension  and  adduction  are  the  causative 
forces.  Hutchinson  maintains  that  supination  may  cause 
subluxation.     Bardenheuer  assigned  falls  as  causes. 


452  A    MANUAL    OF  SURGERY. 

The  syuiptoDis  are  very  characteristic.  The  history  points 
to  the  injury.  Pain,  and  often  a  chck,  may  be  felt  in  the 
wrist  at  the  time  of  the  accident.  The  arm  hangs  by  the 
side,  with  the  elbow-joint  slightly  flexed  and  the  forearm 
midway  between  pronation  and  supination.  Flexion  to  a 
less  angle  than  60°  and  complete  extension  are  resisted  and 
are  very  painful,  but  movements  between  60°  and  130'^  are 
free  and  painless.^  The  movements  of  the  wrist-joint  are 
free  and  painless.  The  elbow-joint  presents  no  deformity. 
Pressure  over  the  head  of  the  radius  causes  pain.  Strong 
pronation  is  painful ;  strong  supination  is  very  painful,  and 
there  seems  to  be  a  mechanical  obstacle  to  its  performance. 
Forced  supination  develops  a  distinct  click  at  the  head  of  the 
radius,  and  causes  pronation  and  supination  to  become  natural 
and  free  from  pain.  The  condition  will  be  reproduced  if  a 
splint  is  not  used.  The  nature  of  the  lesion  is  not  understood, 
and  various  conditions  have  been  thought  to  exist  by  different 
observers.  Among  them  may  be  mentioned  the  following  :  a 
slight  anterior  displacement  of  the  head  of  the  radius ;  a 
slight  posterior  displacement ;  locking  of  the  tuberosity  of  the 
radius  behind  the  inner  edge  of  the  ulna ;  dislocation  of  the 
triangular  cartilage  of  the  wrist;  intracapsular  fracture  of 
the  radial  head;  painful  paralysis  from  nerve-injury;  dis- 
placement by  elongation,  the  return  of  the  bone  being  pre- 
vented by  collapse  of  the  capsule ;  and  the  slipping  up  of 
the  margin  of  the  orbicular  ligament  over  the  rim  of  the 
head  of  the  radius. 

TreaUnent — Place  the  forearm  at  a  right  angle  to  the  arm 
and  make  forcible  supination ;  apply  an  anterior  angular 
splint,  and  have  it  worn  for  four  or  five  days. 

Dislocations  of  the  wrist,  which  are  very  rare,  are 
caused  by  falls  upon  the  hand. 

1  See  the  able  and  learned  article  of  W.  W.  Van  Arsdale  in  the  Annals  of 
Surgery,  vol.  ix.,   1 889. 


DISEASES  AND   INJURIES    OF  BONES  AND  JOINTS.      453 

Backward  Dislocation  of  the  "Wrist. — Symptoms. — The 
deformity  in  backward  dislocation  of  the  wrist  (Fig.  75,  a) 
resembles  that  of  Colles's  fracture  (Fig.  75,  b).  The  fingers 
are  flexed,  the  wrist  is  bent  backward,  the  radius  projects 
on  the  front  of  the  wrist,  the  carpus  projects  on  the  dorsal 
surface  of  the  arm,  the  relation  of  the  styloid  process  of  the 
radius  to  the  styloid  process  of  the  ulna  is  unaltered  (it  is 
altered,  in  Colles's  fracture),  there  is  rigidity,  and  crepitus  is 
absent  (Fig.  75). 


Fig.  75. — Deformity  in  Dislocation  of  the  Wrist  Backward  (a)  and  in  Colle's  Fracture  (b) 
(Stimson). 

Forward  dislocation  of  the  wrist,  which  is  ver}'  unusual, 
is   caused  by  a  fall   upon  the  back  of  the  hand. 

Symptoms  and  Treatment. — In  forward  dislocation  of  the 
wrist  the  radius  and  ulna  project  posteriorly  and  the  carpus 
projects  in  front.  The  treatment  in  both  of  these  dislocations 
is  extension  and  manipulation,  a  Bond  splint  for  ten  days, 
and  passive  motion  after  five  or  six  days. 

Dislocation  at  the  inferior  radio -ulnar  articulation, 
which  is  also  very  rare,  is  caused  by  twists. 

Symptoms  and  Ti'eatment. — In  fonvard  dislocation  at  the 
inferior  radio-ulnar  articulation  the  forearm  is  pronated,  the 
space  between  the  styloid  processes  is  diminished,  and  the 
ulna  forms  a  projection  posteriorly.  In  hackivard  disloca- 
tion the  forearm  is  supinated,  the  space  between  the  styloid 
processes  is  diminished,  and  the  ulna  projects  in  front.  The 
treatment  is  extension  and  manipulation.  Two  straight  splints 
(as  in  fracture  of  both  bones)  are  to  be  applied  for  four 
weeks,  and  passive  motion  is  to  be  made  in  the  third  week. 


454  A   MANUAL    OF  SURGERY. 

Dislocation  of  Individual  Carpal  Bones. — Pick  says 
there  is  one  weak  spot,  which  is  "  between  the  head  of  the 
OS  magnum  and  the  scaphoid  and  semilunar  bones,"  and  the 
OS  magnum  may  be  forced  up.  The  os  magnum  is  the  only 
bone  dislocated  with  any  frequency,  and  the  injury  is  caused 
by  forced  flexion  of  the  wrist. 

Symptoms  and  Treatment. — The  symptom  of  dislocation 
of  the  carpal  bones  is  a  firm  projection  which  becomes  more 
prominent  during  flexion  of  the  wrist.  The  treatmoit  is 
extension  and  manipulation,  a  Bond  splint  being  worn  for 
three  weeks. 

Dislocations  of  metacarpal  bones  are  rare.  The  first 
metacarpal  bone  is  most  liable  to  dislocation. 

Symptoms  ami  Treatment. — Dislocations  of  the  metacarpal 
bones  are  obvious  because  of  projection.  The  treatment  is 
extension  and  manipulation,  a  straight  splint  and  large  pad 
for  the  palm  (as  in  fracture  of  the  metacarpus),  the  splint  to 
be  worn  for  three  weeks. 

Dislocations  at  the  metacarpo -phalangeal  articulations 
are  rare,  and  backward  dislocation  is  the  rule.  The  cause 
is  a  fall  upon  the  hand. 

Symptoms  and  Treatment. — Dislocated  metacarpo-phalan- 
geal  articulations  are  obvious.  Reduction  is  easily  effected, 
except  in  the  case  of  the  thumb.  A  splint  must  be  worn 
for  three  weeks. 

Dislocation  of  the  Metacarpo-phalang-eal  Joint  of  the 
Thumb. — In  this  dislocation  the  phalanx  usually  passes 
backward. 

Symptoms. — Symptoms  of  backward  dislocation  are — the 
base  of  the  first  phalanx  rests  upon  the  metacarpal  bone ; 
the  head  of  the  metacarpal  bone  projects  forward  and  button- 
holes the  muscles  of  the  thumb  ;  the  first  phalanx  of  the 
thumb  is  strongly  extended,  and  the  terminal  phalanx  is 
semiflexed.     The  symptoms  q{  forzvard  dislocation  are — the 


DISEASES  AA'I)    INJURIES    OF  BONES  AND  JOINTS.      455 

base  of  the  first  phalanx  is  felt  in  the  palm,  and  the  head  of 
the  metacarpal  bone  is  felt  posteriorly. 

Trcatuieiit. — In  treating  backward  dislocation  of  the  meta- 
carpo-phalangeal  joint  of  the  thumb,  reduction  is  difficult 
because  of  the  head  of  the  bone  being  caught  in  the  perfora- 
tion of  the  flexor  muscle.  Always  give  ether.  Keetley's 
directions  are  to  adduct  the  metacarpal  bone  into  the  palm 
(to  relax  the  muscles)  and  to  have  an  assistant  hold  it; 
bend    the    thumb    strongly    back,   extend,  pull    the    thumb 


Fig.  76. — Levis  Splint  for  Reducing  Dislocation  of  Phalanges. 


Fig.  77. — Levis  Splint  Applied. 

toward  the  fingers,  and  suddenly  flex.  To  get  a  firm 
enough  grasp  for  these  manipulations,  use  the  apparatus 
of  Charriere  or  of  Levis  (Figs,  y^,  yy).  If  the  above 
manoeuvres  fail,  perform  tenotomy  or  incise  freely  and 
reduce.  After  reduction  of  this  dislocation  a  splint  must 
be  worn  for  three  weeks.  In  forward  dislocation  reduction 
is  easily  effected  by  strong  extension  and  forced  flexion. 
A  splint  is  to  be  worn  for  three  weeks. 

Dislocations  of  the  phalanges  may  be  complete  or  may  be 
partial.  They  are  commonest  between  the  first  and  second 
phalanges. 


456  A   MANUAL    OF  SURGERY. 

Syviptoiiis  and  Treatment. — Dislocations  of  the  phalanges 
arc  obvious.  In  treating  such  dislocations,  employ  extension 
and  manipulation,  and  a  splint  for  one  week. 

Dislocations  of  the  Ribs  and  Costal  Cartilages. — The 
ribs  may  be  dislocated  from  the  vertebrae.  This  accident  is 
rarely  uncomplicated,  and  cannot  be  differentiated  from  frac- 
ture. The  diagnosis  is  rarely  made,  and  the  injury  is  treated 
as  a  fracture.  The  ribs  may  be  dislocated  from  their  carti- 
lages, one  or  more  ribs  being  displaced.  The  end  of  the  rib 
forms  an  anterior  projection,  there  is  a  depression  over  the 
cartilage,  and  crepitus  is  absent.  Treatment  is  the  same  as 
that  employed  for  fractured  ribs.  The  costal  cartilages  may 
be  displaced  from  the  sternum,  forming  an  anterior  projec- 
tion upon  this  bone.  Reduction  is  brought  about  by  placing 
the  patient  upon  a  table  with  a  sand  pillow  between  the 
scapulae,  pushing  back  the  shoulders  and  chest,  and  forcing 
the  cartilage  into  place.  The  dressings  are  the  same  as  those 
used  in  fractured  sternum.  The  cartilages  of  the  lower  ribs 
(sixth,  seventh,  eighth,  ninth,  and  tenth)  may  be  separated. 
The  inferior  cartilage  goes  forward  and  can  be  felt.  Pick 
states  that  reduction  is  brought  about  by  causing  the  patient 
to  hold  the  chest  full  of  air  while  efforts  are  made  to  push 
the  cartilage  into  place.     Dress  as  for  fractured  ribs. 

Dislocations  of  the  Sternum. — In  dislocations  of  the 
sternum  the  manubrium  may  be  separated  from  the  gladio- 
lus in  young  subjects.  The  symptoms  and  treatment  are  the 
same  as  those  in  fracture  (p.  342). 

Pelvic  dislocations  are  almost  always  complicated  with 
fracture.  A  pubic  bone  can  be  dislocated  by  falls  from  a 
height  or  by  applying  violent  force  to  the  acetabula.  The 
dislocation  may  be  up  or  down,  front  or  back,  and  it  may 
damage  the  urethra  or  the  bladder.  The  patient  cannot 
.stand;  there  are  great  pain  and  recognizable  deformity.  Treat 
by  moulding  the  bones  into  place,  by  applying  a  pelvic  belt, 


DISEASES  AND  INJURIES   OF  BONES  AND  JOINTS.      457 

and  by  rest  in  bed  for  four  weeks.  Dislocations  of  the 
sacro-iliac  joint  are  produced  by  falls.  JMov^ement  on  the 
part  of  the  patient  is  difficult  or  impossible;  there  is  violent 
pain,  and  often  paralysis  (from  pressure  upon  nerves).  In 
dislocation  backward  there  is  an  apparent  shortening  of  the 
leg,  eversion  of  the  foot  exists,  and  the  ilium  moves  poste- 
riorly and  upward.  In  dislocation  forward  the  anterior  supe- 
rior iliac  spine  projects  and  the  pelvis  is  broadened.  Sacro- 
iliac dislocations  are  reduced  by  holding  the  pelvis  firm  and 
making  extension  with  a  pulley.  The  patient  stays  in  bed 
for  four  weeks  and  wears  a  pelvic  belt  as  in  fracture. 

Dislocations  of  the  Femur  (Hip-joint). — These  injuries 
are  rare,  as  the  hip-joint  is  very  strong.  They  occur  in 
young  adults.  In  forcible  extension  the  head  of  the  femur 
presses  against  the  capsule,  but  the  capsule  here  is  very 
thick,  and  certain  muscles,  the  rectus,  psoas,  and  iliacus,  are 
pulled  tight  and  serve  to  strengthen  the  capsule.  The  head 
of  the  bone  cannot  go  directly  upward,  because  of  the  ace- 
tabulum (Edmund  Owen).  The  weak  point  of  the  acetabular 
rim  is  below ;  the  weak  part  of  the  capsule  is  also  below ; 
hence  forced  abduction  is  apt  to  take  the  head  of  the  bone 
through  the  lower  part  of  the  capsule,  a  dislocation  occur- 
ring primarily  into  the  thyroid  foramen.  Four  forms  of 
hip-joint  dislocation  exist:  (i)  upward  and  backward,  on 
the  dorsum  of  the  ilium ;  (2)  backward,  into  the  sciatic 
notch  ;  (3)  downward,  into  the  obturator  foramen  ;  and  (4) 
inward,  on  the  pubes. 

Dislocation  on  to  the  dorsum  of  the  ilium  comprises  one- 
half  of  all  hip-dislocations.  It  is  caused  by  a  fall  or  a  blow 
when  the  limb  is  flexed  and  abducted  (as  in  carr}'ing  a 
weight  upon  the  shoulder),  by  a  fall  upon  the  knees  or  feet, 
by  a  weight  striking  the  back  while  bending,  etc.  In  this 
dislocation  the  head  of  the  femur  goes  upward  and  back- 
ward, rests  upon  the  ilium,  and  is  always  above  the  tendon 


458  A   MANUAL    OF  SURGERY. 

of  the  obturator  intcrnus  muscle.  This  dislocation  is  sec- 
ondary to  a  thyroid  dislocation,  because  of  muscular  action 
shifting  the  bone  from  its  initial  seat  of  displacement. 

Symptoms. — Dislocation  on  to  the  dorsum  of  the  ilium  is 
indicated  by  the  following  symptoms  :  The  buttock  looks  flat 
and  broad  ;  the  great  trochanter  is  above  Nelaton's  line  and 
is  deeply  placed  ;  the  head  of  the  bone  can  be  detected  in  its 
new  situation  ;  deep  pressure  in  front  of  the  joint  finds  a 
hollow ;  the  leg  is  shortened  by  about  two  or  three  inches, 
as  a  rule ;  the  knee  is  slightly  flexed  ;  the  thigh  is  slightly 
flexed,  inwardly  rotated,  and  adducted  (Fig.  78)  (this  is 
shown  by  the  fact  that  the  axis  of  the  thigh  of  the  injured 
side,  if  prolonged,  would  pass  through  the  lower  third  of  the 
sound  thigh)  ;  the  heel  is  raised,  and  the  great  toe  of  the  foot 
of  the  injured  side  rests  upon  the  front  of  the  instep  or  the 
ankle  of  the  sound  side ;  the  fascia  lata  is  relaxed ;  rigidity 
exists ;  voluntary  movement  is  impossible,  though  some  pas- 
sive motion  is  possible  in  the  direction  of  the  deformity  (the 
deformity  can  be  made  more  marked). 

The  diagnosis  from  intracapsular  fracture  is  obtained  by 
noting  the  inversion,  the  great  shortening,  the  absence  of 
crepitus,  the  age  of  the  subject,  and  the  nature  of  the  force. 
The  nature  of  the  force,  the  inversion,  and  the  absence  of 
crepitus  mark  the  diagnosis  from  extracapsular  fracture. 

Treatment. — The  chief  obstacle  to  reduction  in  dislocation 
on  to  the  dorsum  of  the  ilium,  Bigelow  states,  is  the  untorn 
portion  of  the  capsule,  especially  the  Y-Hgament.  The  ilio- 
femoral, Y,  or  Bigelow's  ligament  resembles  an  inverted  Y, 
arises  from  the  anterior  inferior  spine  of  the  ilium,  is  inserted 
into  the  anterior  intertrochanteric  line,  and  is  incorporated 
into  the  front  of  the  capsule.  To  reduce  a  dislocation  this 
ligament  must  be  relaxed  by  manipulation  or  be  torn  by 
extension.  Manipulation  makes  the  head  of  the  bone  re- 
trace its  steps  over  the  same  route  it  took  in  emerging.     Give 


DISEASES  AXD   L\JURIES    OF  BONES  AND  JOINTS.      459 


Fig.     79-  —  Reduction     of    Dislocation    on    the 
Dorsum  of  the  Ilium  by  the   Pulleys  (Cooper). 


Fig.  78.  — Hip- 
joint  Dislocation  : 
Upward,  or  on  the 
dorsum  of  the  ilium 
(Cooper). 


or^ 


Fig.  81.— Reduction  of  Dislocation  into  the    . 
Sciatic  Notch  by  the  Pulleys  (Cooperj.  7^ 


Fig.  82.  — Hip- 
joint  Dislocation  : 
Downward,  into 
the  obturator  or 
thyroid  foramen 
(Cooper). 


Fig.  Bo. — Hip-joint 
Dislocation:  Back- 
ward, or  into  the  sci- 
atic notch  (Cooper). 


Fig.  83.— Reduction  of  Dislocation  into  the 
Obturator  Foramen  by  the  Pulleys  (Cooper). 


Fig.  85.— Reduction  of  Dislocation  on  the  Pubes  by  the  Pulleys 
(Cooper). 


Fig.  84.  —  Disloca- 
tion on  the  Pubes 
(Cooper). 


460  A    MANUAL    OF  SURGERY. 

ether  ;  place  the  patient  supine  upon  a  mattress  on  the  floor  ; 
flex  the  leg  on  the  thigh  (to  relax  the  hamstrings),  the  thigh 
on  the  pelvis  ;  increase  the  adduction  over  the  middle  line ; 
strongly  abduct;  perform  external  rotation  and  extension. 
This  treatment  may  be  summed  up  as  flexion,  adduction, 
external  cirumduction,  and  extension  ;  or,  as  Pick  puts  it, 
"  bend  up,  roll  out,  turn  out,  and  extend."  If  manipula- 
tion fails,  try  extension.  A  perineal  band  is  fastened  to  the 
wall,  and  extension  by  pulleys  is  made  in  the  axis  of  the  de- 
formed limb — that  is,  across  the  lower  third  of  the  other 
thigh  (Fig.  79),  or  at  a  right  angle  to  the  body  while  the 
patient  lies  upon  the  sound  side.  After  reduction  put  the 
patient  to  bed  and  use  sand-bags  (as  in  fracture  of  the 
hip)  for  four  weeks.  Passive  motion  is  made  in  the  third 
week. 

Dislocation  into  the  Sciatic  Notch. — In  this  dislocation 
the  head  of  the  bone  passes  backward  and  a  little  upward, 
and  rests  upon  the  ischium  at  the  margin  of  the  sciatic 
notch  (not  in  the  notch),  below  the  tendon  of  the  obturator 
internus  muscle.  The  causes  are  the  same  as  those  given  for 
the  previous  dislocation. 

Symptoms. — The  signs  in  dislocation  into  the  sciatic  notch 
are  like  those  of  dislocation  upon  the  dorsum  of  the  ilium, 
but  they  are  not  so  marked.  There  are  flattening  and 
broadening  of  the  hip ;  ascent  of  the  trochanter  above  Nela- 
ton's  line ;  shortening  to  the  extent  of  an  inch.  Flexion, 
inward  rotation,  and  adduction  exist,  but  the  axis  of  the 
femur  of  the  injured  side  passes  through  the  knee  of  the 
sound  side,  and  the  ball  of  the  great  toe  of  the  injured 
side  rests  upon  the  great  toe  of  the  sound  side  (Fig.  80). 
Other  symptoms  are  identical  with  dislocation  upon  the 
dorsum  of  the  ilium,  but  are  less  pronounced.  Allis's  signs 
of  this  dislocation  are  of  value:  if,  with  the  patient  recum- 
bent, the  thighs  are  brought  to  a  right  angle  with  the  body. 


DISEASES  AND   INJURIES    OE  BONES  AND  JOINTS.      46 1 

shortening  on  the  affected  side  is  materially  increased ;  if  the 
dislocated  thigh  is  extended,  the  back  arches  as  in  hip  disease. 

Diagnosis  and  Trcatmoit. — The  symptoms  of  dislocation 
into  the  sciatic  notch  are  similar  to,  but  are  less  marked 
than,  those  of  dorsal  dislocation,  and,  being  a  backward 
dislocation,  the  reduction  and  treatment  are  the  same  as  for 
dislocation  backward  upon  the  dorsum  of  the  ilium  (Fig,  81). 

Dislocation  Downward  into  the  Obturator  Foramen. — 
Downward  dislocation  is  the  primary  position  of  most  dislo- 
cations of  the  hip,  the  bone  rarely  remaining  in  the  thyroid 
foramen,  but  usually  mounting  up  as  a  result  of  muscular 
action  or  of  the  initial  violence.  The  cause  is  violent  abduc- 
tion by  falls  or  by  stepping  from  a  moving  car. 

Symptoms. — Dislocation  downward  into  the  obturator  fora- 
men is  indicated  by  flattening  of  the  hip  ;  the  head  of  the  bone 
is  felt  m  its  new  position  and  is  missed  from  the  acetabulum  ; 
rigidit}^  except  in  the  direction  of  deformity ;  a  hollow  over 
the  great  trochanter,  which  process  is  well  below  Nelaton's  line 
and  nearer  than  normal  to  the  middle  line  ;  the  gluteal  crease 
is  lower  than  is  the  crease  of  the  opposite  side ;  lengthening 
to  the  extent  of  one  to  two  inches ;  the  body  is  bent  forward 
by  the  traction  upon  the  psoas  and  iliacus  muscles,  and  is 
also  deviated  to  the  side,  thus  causing  great  apparent  length- 
ening;  the  limb  is  advanced  and  abducted,  and  the  foot  is 
pointed  straight  ahead  or  is  a  little  everted  (Fig.  82) ;  when 
the  patient  is  recumbent  extension  is  impossible,  the  knees 
cannot  be  pushed  together  without  great  pain,  and  the  adduc- 
tor muscles  are  hard  and  rigid.  Unreduced  dislocations  do 
well,  the  patient  obtaining  a  very  useful  hip-joint  (Sedillot). 

Ti'catmcnt. — In  treating  dislocation  downward  into  the 
obturator  foramen,  effect  reduction  if  possible  by  manipula- 
tion, and  if  this  fails  by  extension.  To  reduce  by  manipu- 
lation, flex  the  leg  on  the  thigh  and  the  thigh  on  the  pelvis, 
and  then  perform,  in  the  following  order,  abduction,  internal 


462  A   MANUAL    OF  SURGERY. 

circumduction,  and  extension.  If  extension  is  used,  employ 
a  pelvic  band  to  pull  the  pelvis  toward  the  sound  side,  and 
a  perineal  band  beneath  the  pelvic  band,  having  pulleys  to 
maintain  force  upward  and  outward  from  the  injured  hip. 
The  surgeon,  grasping  the  leg  and  ankle,  drags  the  member 
inward  and  pries  the  femur  into  place  (Keetley;  Fig.  83). 
The  after-treatment  is  the  same  as  that  for  the  previous  forms. 

Dislocation  into  the  pubes  is  very  rare.  The  head  of 
the  bone  usually  rests  just  internal  to  the  anterior  inferior 
spine  of  the  ilium.  The  primary  position  of  the  bone  is  in 
the  thyroid  foramen ;  the  pubic  dislocation,  when  it  occurs, 
is  always  secondary,  and  is  due  to  the  initial  force  and  to 
muscular  action. 

Symptoms. — In  pubic  dislocation  the  head  of  the  bone  can 
be  felt  and  seen  in  its  new  position ;  the  hip  is  flattened  ; 
there  is  a  hollow  over  the  great  trochanter,  this  process 
being  found  below  the  anterior  superior  spine  of  the  ilium  ; 
there  is  shortening  to  the  extent  of  an  inch  ;  the  limb  is  in 
abduction  with  eversion  (Fig.  84),  and  the  knees  cannot  be 
approximated  without  great  pain. 

Treatment. — The  treatment  of  pubic  dislocation  is  manip- 
ulation as  performed  for  thyroid  dislocation.  If  this  fails, 
employ  extension.  The  limb,  is  well  abducted,  extension  is 
made  downward  and  backward,  and  the  head  of  the  femur 
is  pulled  outward  "  by  a  towel  around  the  thigh,  just  beneath 
the  groin"  (Keetley;  Fig.  85).  The  after-treatment  is  the 
same  as  that  for  the  previous  forms. 

Anomalous  Dislocations  of  the  Hip. — In  supraspinous 
dislocation  the  dislocation  of  the  hip  is  backward,  the  head 
of  the  femur  resting  upon  the  ilium  above  or  even  anterior 
to  the  anterior  superior  spine.  In  ischial  dislocation  the  dis- 
location is  downward  and  backward,  the  head  of  the  femur 
resting  on  the  ischial  tuberosity  or  in  the  lesser  sciatic  notch. 
Monteggids  dislocation  is  a  supraspinous   dislocation  with 


DISEASES  AND   IXJ CRIES   OF  BOXES  AND  JOEVTS.      463 

eversion  of  the  limb.  In  perineal  dislocation  the  head  of  the 
femur  is  in  the  perineum.  In  suprapubic  dislocation  the  head 
of  the  femur  passes  above  the  pubes.  In  subspinous  disloca- 
tion the  femoral  head  rests  on  the  horizontal  ramus  of  the 
pubes. 

Dislocations  of  the  Knee. — These  dislocations  are  rare. 
There  are  four  forms — forward,  backward,  inward,  and  out- 
ward. They  may  be  complete  or  be  incomplete ;  the  com- 
monest dislocations  are  lateral.  The  cause  is  violent  force, 
such  as  a  fall,  or  in  jumping  from  a  moving  train,  or  in 
being  caught  by  the  foot  and  dragged. 

Dislocation  Forward  of  the  Knee-joint. — In  the  com- 
plete form  of  forward  dislocation  the  deformity  is  obvious. 
The  limb  is  usually  extended,  but  it  may  be  flexed.  Much 
shortening  exists  ;  the  condyles  are  felt  posterior  and  below; 
the  head  of  the  tibia  is  felt  anterior  and  above ;  the  patella  is 
movable  and  the  quadriceps  is  lax ;  pressure  of  the  condyles 
upon  the  contents  of  the  popliteal  space  stops  the  tibial 
pulse  and  causes  oedema  and  intense  pain.  In  incomplete 
dislocation  the  symptoms  are  identical  in  kind,  but  are  less 
pronounced. 

Treatment. — Compound  dislocation  of  the  knee-joint  often 
demands  excision  or  amputation.  In  simple  dislocation  give 
ether.  One  assistant  extends  the  leg,  another  makes  coun- 
ter-extension on  the  thigh,  and  the  surgeon  pushes  the  bone 
into  place.  Reduction  is  easy  because  of  ligamentous  lacera- 
tion. Place  the  limb  on  a  double  inclined  plane,  and  combat 
inflammation  by  the  usual  methods  (see  Synovitis,  p.  395). 
Begin  passive  motion  in  the  third  week.  The  patient  must 
wear  a  knee-support  for  months.  If  the  popliteal  vessels 
are  much  damaged,  gangrene  will  supervene  and  amputa- 
tion will  be  demanded. 

Dislocation  Backward  of  the  Knee-joint. — In  the  com- 
plete form  of  knee-joint  dislocation  backward  displacement 


464  A   MANUAL    OF  SURGERY. 

is  not  SO  great  as  in  dislocation  forward.  The  head  of  the 
tibia  projects  posteriorly  and  above,  the  femoral  condyles 
anteriorly  and  below ;  the  leg  is,  as  a  rule,  partly  flexed, 
but  it  may  be  extended,  and  there  is  moderate  shortening. 
In  i)ico7nplete  dislocation  the  symptoms  are  less  marked. 

Treatment. — The  treatment  of  backward  dislocation  of  the 
knee-joint  is  the  same  as  for  forward  dislocation. 

Dislocation  Outward  of  the  Knee-joint. — The  inner 
tuberosity  of  the  tibia  in  outward  dislocation  lies  upon  the 
outer  condyle  of  the  femur  (Pick) ;  the  inner  condyle  of  the 
femur  projects  internally ;  the  outer  tibial  tuberosity  and 
fibular  head  project  externally,  the  former  having  a  depres- 
sion below  it,  and  the  latter  above  it ;  the  leg  is  semiflexed, 
but  shortening  is  absent. 

Dislocation  Inward  of  the  Knee-joint. — The  outer  tuber- 
osity of  the  tibia  in  inward  dislocation  lies  upon  the  inner 
condyle  of  the  femur;  the  outer  condyle  of  the  femur  forms 
an  external  prominence,  and  the  inner  tuberosity  of  the  tibia 
forms  an  internal  prominence.  Pick  cautions  us  not  to  mis- 
take a  separation  of  the  lower  femoral  epiphysis  for  lateral 
dislocation  (the  former  is  reduced  easily,  the  deformity  tends 
to  recur,  and  there  is  soft  crepitus). 

Treatment. — In  treating  lateral  dislocation  of  the  knee- 
joint,  effect  extension  and  counter-extension  as  in  antero- 
posterior dislocations.  The  leg  is  moved  from  side  to  side 
and  attempts  are  made  at  rotation.  The  after-treatment  is 
the  same  as  that  for  antero-posterior  luxations. 

Lateral  dislocations  of  the  knee-joint  are  usually  incom- 
plete. 

Dislocation  of  the  Semilunar  Cartilages  of  the  Knee 
(the  Internal  Derangement  of  Mr.  Hey;  Subluxation). — These 
interarticular  cartilages  are  attached  in  front  of  and  behind 
the  tibial  spine,  and  their  convexity  is  attached  to  the  edge 
of  the  tibial  tuberosities   by  the   coronary  ligament.     The 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      465 

inner  cartilage  is  connected  with  the  internal  lateral  liga- 
ment, and  it  has  a  moderate  freedom  of  movement ;  the 
outer  cartilage  is  not  connected  with  the  external  lateral 
ligament,  and  is  not  freely  movable,  yet  the  outer  is  more 
often  dislocated  than  is  the  inner  cartilage.  The  cause  is 
a  twist  when  the  knee  is  flexed,  as  in  stubbing  the  toe. 

Symptoms. — The  indications  of  interarticular-cartilage  dis- 
location are  a  sudden  violent,  sickening  pain  in  the  knee,  that 
may  cause  the  patient  to  fall ;  the  position  is  one  of  fixed 
semiflexion,  voluntary  motion  being  impossible  and  passive 
motion  causing  fierce  pain  ;  a  displacement  of  either  cartilage 
away  from  the  tibial  spine  produces  a  prominence  on  one  or 
the  other  side  of  the  knee-joint,  and  a  displacement  toward 
the  tibial  spine  makes  a  prominence  on  one  side  of  the  liga- 
ment of  the  patella.  Subluxation  is  soon  followed  by  in- 
flammation, and  swelling  rapidly  masks  the  projection.  This 
accident  is  usually  mistaken  for  blocking  of  a  joint  by  a 
floating  cartilage. 

Trcatmoit. — In  treating  dislocation  of  the  semilunar  carti- 
lages of  the  knee,  reduce  by  forced  flexion  and  sudden  exten- 
sion with  rotation,  at  the  same  time  endeavoring  to  push 
the  projecting  cartilage  into  place.  After  reduction  combat 
inflammation,  apply  a  splint,  and  use  the  proper  remedies 
for  one  week  (see  Synovitis^,  then  begin  passive  motion. 
As  recurrence  of  the  displacement  is  usual,  the  patient  should 
wear  a  knee-cap  for  a  year  or  more.  If  reduction  is  impos- 
sible, persistent  passive  motion  will  secure  a  useful  joint. 

Dislocations  of  the  Fibula :  Dislocation  at  the  Supe- 
rior Tibio-fibular  Articulation. — This  injury  is  rare.  The 
head  of  the  fibula  may  go  forward  or  backward.  The  causes 
are  direct  force  and  violent  adduction  of  the  foot  with  abduc- 
tion of  the  knee  (Bryant). 

Symptoms. — In  dislocation  of  the  fibula  the  position  is 
one  of  semiflexion,  voluntary   extension  and   flexion  being 

30 


466  A   MANUAL    OF  SURGERY. 

impaired  or  lost.  A  distinct  movable  projection  is  readily 
noticed  in  front  or  behind,  which  is  found  to  be  continuous 
with  the  fibula.  There  is  a  depression  over  the  normal  posi- 
tion of  the  head  of  the  fibula. 

T^'catment. — In  treating  dislocation  of  the  fibula,  bend  the 
knee  to  relax  the  biceps,  and  proceed  to  push  the  bone  into 
place.  Put  a  compress  over  the  head  of  the  fibula,  apply 
a  bandage,  and  put  the  limb  on  a  double  inclined  plane  for 
three  weeks.  At  the  end  of  this  time  put  a  lacing  knee- 
support  upon  the  knee  and  let  the  patient  up.  Displacement 
being  liable  to  recur,  a  knee-cap  must  be  worn  for  a  year. 

Dislocations  of  the  Ankle-joint. — These  injuries  are  not 
unusual.  Fracture  is  a  frequent  complication.  There  are 
five  forms  of  ankle-joint  dislocation — outward,  inward,  for- 
ward, backward,  and  upward. 

Lateral  dislocations  of  the  ankle-joint  are  either  out- 
ward and  inward,  and  may  be  complete  or  incomplete.  In 
these  dislocations  the  astragalus  rotates.  In  incomplete  dis- 
locations "  there  is  no  great  separation  of  the  trochlear  sur- 
face of  the  astragalus  .from  the  under  surface  of  the  tibia, 
but  the  outer  or  inner  margin  of  this  surface  is  brought  into 
contact  with  the  articular  surface  of  the  tibia,  and  the  whole 
foot  presents  a  lateral  twist "  (Pick).  The  causes  of  these 
dislocations  are  twists  of  the  joint. 

Symptoms. — Incomplete  outward  dislocation  of  the  ankle- 
joint  is  known  as  Pott's  fracture  (see  p.  391),  and  complete 
outward  dislocation,  in  which  the  articular  surface  of  the 
astragalus  is  completely  displaced  from  the  articular  surface 
of  the  tibia,  is  known  as  Diipuytrcn  s  fracture.  In  incom- 
plete dislocation  the  foot  goes  outward  and  upward,  the 
fibula  is  fractured,  and  the  tibio-fibular  ligaments  are  torn 
off.  In  Dupuytren's  fracture  the  ankle  is  broad,  the  inner 
malleolus  projects  and  looks  lower  than  natural,  the  outer 
malleolus  ascends  with  the  foot,  the  foot  rotates  outward, 


DISEASES  AND   IXJ CRIES   OF  BONES  AND  JOINTS.      467 

and  crepitus  can  be  found.  In  inward  dislocation  which  is 
associated  with  fracture  of  the  inner  malleolus  there  is 
inversion,  the  outer  malleolus  projects,  and  crepitus  can  be 
found.  In  incomplete  separation  the  symptoms  are  similar, 
but  are  not  so  marked. 

Treatment. — In  treating  outward  dislocation  of  the  ankle- 
joint  the  deformity  is  reduced  by  flexing  the  leg  on  the 
thigh  and  the  thigh  on  the  pelvis  ;  an  assistant  makes  coun- 
ter-extension from  the  knee ;  the  surgeon  makes  extension 
from  the  foot,  and  at  the  same  time  rocks  the  astragalus 
into  place.  Dupuytren's  fracture  is  treated  in  the  same 
manner  as  Pott's  fracture  (p.  391).  Dislocation  inward  is 
treated  in  a  fracture-box  for  the  same  period  as  Pott's 
fracture. 

Antero-posterior  dislocations  of  the  ankle-joint  are 
rare.  The  eause  is  the  catching  of  the  foot  in  jumping  or 
falling — direct  violence.  In  dislocation  forward  the  foot  is 
lengthened,  the  heel  is  not  conspicuous,  the  tibia  and  fibula 
project  against  the  tendo  Achillis,  and  the  relation  of  the 
malleoli  to  the  tarsus  is  altered.  In  incomplete  dislocation 
the  symptoms  are  similar,  but  less  pronounced.  In  disloca- 
tion backward  the  foot  is  shortened,  the  tibia  and  fibula 
project  in  front,  the  heel  is  prominent,  and  the  relation 
between  the  malleoli  and  the  tarsus  is  altered.  In  incom- 
plete dislocation  the  symptoms  are  similar,  but  less  marked. 

Treatment. — In  antero-posterior  dislocation  of  the  ankle- 
joint,  reduce  as  in  lateral  dislocations.  Sometimes  the 
tendo  Achillis  must  be  cut.  Apply  a  silicate-of-soda  dress- 
ing, and  let  it  be  worn  for  two  weeks  ;  then  begin  passive 
motion,  and  let  the  patient  wear  side-splints  for  a  week 
longer. 

Dislocation  upward  of  the  ankle-joint  is  a  very  rare 
injury.  The  astragalus  wedges  in  between  the  widely-sepa- 
rated tibia  and  fibula.     This  dislocation  is  usually  associated 


468  A    MANUAL    OF  SURGERY. 

with  fracture.  The  cause  is  a  fall  upon  the  feet  from  a 
great  height. 

Symptoms. — Upward  dislocation  of  the  ankle-joint  is  indi- 
cated by  the  widening  of  the  ankle  and  by  the  flattening  of 
the  foot.  The  malleoli  are  nearly  on  a  level  with  the  plantar 
surface  of  the  foot,  and  there  is  absolute  rigidity. 

Treatment. — In  treating  upward  dislocation  of  the  ankle- 
joint,  give  ether  and  try  to  reduce  by  powerful  extension 
and  counter-extension.  Treat  the  injury  afterward  as  in 
antero-posterior  luxation. 

Dislocation  of  the  Astragalus. — The  astragalus  may  be 
displaced  from  the  bones  of  the  leg  and  at  the  same  time 
be  separated  from  the  rest  of  the  tarsus.  The  displacement 
may  be  forward,  backward,  outward,  inward,  or  rotary. 

Dislocation  of  the  astragalus  forward  or  backward 
is  caused  by  falls  or  twists. 

Symptoms. — In  forward  dislocation  the  astragalus  projects 
strongly ;  there  is  shortening  of  the  foot,  and  the  malleoli 
approach  the  plantar  aspect  of  the  foot ;  the  foot  is  deviated 
to  one  side  or  to  the  other,  and  there  is  absolute  rigidity 
of  the  ankle-joint.  In  incomplete  luxations  the  symptoms 
are  similar,  but  less  marked.  This  dislocation  may  be 
obliquely  forward.  In  backward  dislocation  of  the  astraga- 
lus the  foot  is  not  deviated  to  either  side ;  the  astragalus 
projects  between  the  malleoli  and  above  the  os  calcis,  and 
the  tendo  Achillis  is  stretched  over  the  projection.  Rigidity 
is  absolute.     This  dislocation  may  be  obliquely  backward. 

Lateral  and  Rotary  Dislocations  of  the  Astragalus. — 
Lateral  dislocations  of  the  astragalus  are  rare,  are  always 
compound,  and  are  always  associated  with  fracture.  In 
rotary  dislocation  the  astragalus  remains  in  its  normal 
habitat  after  rotating  on  its  own  axis,  either  horizontal  or 
vertical.  The  causes  of  rotary  dislocation  are  twists  of  the 
foot  when  at  a  right  angle  to  the  leg  (Barwell).     The  symp- 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      469 

tonis  of  rotary  dislocation  are  obscure.     There  is  rigidity, 
but  sometimes  portions  of  the  astragalus  may  be  made  out. 

Treatment  of  Dislocations  of  the  Astragalus. — In  treating 
astragalus  dislocation,  reduce  under  ether  by  flexing  the 
knee  to  relax  the  gastrocnemius,  extending  the  foot,  and 
pushing  the  bone  into  place.  It  may  be  necessary  to  cut 
the  tendo  Achillis.  After  reduction  put  up  the  foot  and  leg 
m  silicate-of-soda  dressing  for  two  weeks,  and  then  begin 
passive  motion  and  apply  side-splints,  which  are  to  be  worn 
for  one  week  more.  If  reduction  fails,  support  the  limb  on 
splints,  combat  inflammation,  and  endeavor  to  bring  about 
union  between  the  dislocated  bone  and  the  tissues.  Often, 
in  unreduced  dislocation,  the  skin  sloughs  over  the  project- 
ing bone.  Excision  is  demanded  the  moment  sloughing  is 
seen  to  be  inevitable.  Cases  of  compound  dislocation  of  the 
astragalus  require  immediate  excision, 

Subastragaloid  Dislocation. — This  condition  is  a  separa- 
tion of  the  astragalus  from  the  os  calcis  and  scaphoid,  with- 
out separation  of  the  astragalus  from  the  bones  of  the  leg. 
Pick  states  that  the  usual  classification  for  these  dislocations 
is  forward,  backward,  inward,  and  outward,  but  that  the  dis- 
placement is,  as  a  rule,  oblique,  the  foot  passing  backward 
and  outward  or  backward  and  inward.    The  causes  are  twists. 

Symptoms. — In  subastragaloid  dislocation  the  astragalus 
projects  on  the  dorsum  ;  the  foot  is  everted  in  outward  dis- 
location and  inverted  in  inward  dislocation  ;  the  relation  of 
the  malleoli  to  the  astragalus  is  unaltered ;  the  ankle-joint  is 
not  absolutely  rigid  ;  the  foot  **  is  shortened  in  front  and  is 
elongated  behind  "  (Pick). 

Ti'eatment. — To  treat  subastragaloid  dislocation,  make 
extension  in  the  direction  opposite  to  that  of  the  displace- 
ment. In  dislocation  of  the  tarsus  backward,  fix  a  bandage 
around  the  foot,  on  a  level  with  the  heads  of  the  metatarsal 
bones,  which  bandage  the  surgeon  ties  around  his  shoulders. 


470  A   MANUAL    OF  SURGERY. 

The  surgeon  puts  one  knee  in  front  of  the  ankle  and  thus 
fixes  the  leg,  raises  himself  up  to  make  extension  upon  the 
tarsus,  and  moulds  the  bone  into  position.  Tenotomy  may 
be  necessary.  After  reduction  apply  a  silicate  dressing  for 
three  weeks.  The  ankle-joint,  fortunately,  is  not  involved, 
and  stiffness  of  this  articulation  need  not  be  apprehended. 
If  reduction  is  impossible,  take  the  same  course  as  in  luxa- 
tions of  the  astragalus. 

Dislocations  of  the  other  tarsal  bones  are  very  rare. 
Single  bones  may  be  dislocated,  or  the  luxation  may  occur 
at  the  medio- tarsal  articulation. 

Symptoms  and  Treatment. — Projection  is  an  obvious 
symptom  in  dislocation  of  the  other  tarsal  bones.  The 
treatment  is  to  reduce  by  extension  and  moulding,  the  part 
being  put  up  in  silicate-of-soda  dressing  for  two  weeks. 

Dislocations  of  the  metatarsal  bones  are  rare. 

Symptoms  and  Treatment. — Shortening  of  the  toes  and 
projection  of  the  dislocated  bone  are  symptoms  of  disloca- 
tion of  the  metatarsal  bones.  To  treat  these  dislocations, 
reduce  by  extension  under  ether  and  put  up  in  a  silicate 
dressing  for  two  weeks.  If  reduction  fails,  the  functions  of 
the  foot  will  not  be  much  impaired. 

Dislocations  of  the  phalang-es  are  very  rare.  The  first 
phalanx  of  the  big  toe  is  the  one  most  liable  to  dislocation. 

Symptoms  a?id  Treatment. — Dislocations  of  the  phalanges 
are  obvious.  The  treatment  is  by  reduction  as  in  disloca- 
tions of  the  thumb.     Immobilize  for  two  weeks. 

5.  Operations  upon  Bones. 
Osteotomy. — By  the  term  osteotomy  the  modern  surgeon 
means  literally  the  sectioning  of  a  bone  for  the  purpose  of 
straightening  a  limb  ankylosed  in  a  bad  position,  correcting 
a  bony  deformity,  or  amending  a  vicious  union  of  a  fracture. 
In  a  linear  osteotomy  the  bone  is  transversely  divided  in  one 


DISEASES  AXD   I XJ CRIES   OF  BONES  AND  JOIXTS.      47 1 

spot;  in  a  cuneiform  osteotomy  a  wedge-shaped  portion  of 
bone  is  removed.  The  operation  of  osteotomy  may  be  per- 
formed with  a  saw  (Fig.  86)  or  with  an  osteotome.  The  saw 
creates  dust,  draws  much  air  into  the  wound,  and  lacerates 
the  tissues  to  a  considerable  degree.  Most  surgeons  prefer 
the  chisel  or  the  osteotome.  The  osteotome  (Fig.  %^^  differs 
from  a  chisel  in  having  two  bevels  instead  of  one. 

Osteotomy  for  Genu  Valg-uni,  or  Knock-knee  (Macewen's 
Operation). — In  this  operation  the  instruments  required  are 


Fig.  86. — Adams's  Large  Saw. 


Fig.  87.— Rawhide  Mallet. 


Fig.  88. — Osteotome. 


the  scalpel,  haemostatic  forceps,  osteotomes  of  several  sizes, 
a  mallet  (Fig.  ^J^,  and  a  sand-bag  wrapped  in  an  aseptic 
towel. 

Operation. — The  patient  lies  upon  his  back,  being  rolled  a 
little  toward  the  diseased  side.  The  leg  of  the  diseased  side  is 
partly  flexed  upon  the  thigh  and  the  thigh  upon  the  pelvis, 
and  the  extremity  is  laid  upon  its  outer  surface,  the  sand-bag 
being  pushed  between  the  extremity  and  the  bed,  opposite  to 
the  site  of  section.  The  flexion  of  the  knee  relaxes  the 
popliteal  vessels  and  saves  them  from  injury.     The  surgeon. 


472 


A    MANUAL    OF  SURGERY. 


if  operating  on  the  right  leg,  stands  outside  of  that  ex- 
tremity ;  if  operating  on  the  left  leg,  he  stands  opposite  the 
left  hip  (Barker),  Enter  the  knife  at  the  inner  side  of  the 
knee,  just  in  front  of  the  adductor  tubercle  of  the  inner  con- 
dyle and  on  a  level  with  the  upper  border  of  "  the  patellar 
articular  surface  of  the  femur"  (Barker);  cut  down  to  the 
bone,  and  make  an  incision  upward  one  inch  in  length,  in 
the  direction  of  the  axis  of  the 
femur.  At  the  lower  angle 
of  this  wound  insert  an  oste- 
otome and  turn  it  to  a  right 


Fig.  89. — Osteotomy  of  the  Right 
Femur  in  a  Case  of  Knock-knee : 
A  B,  epiphyseal  line;  c,  section  of 
Macewen ;     d  e,    section    of  Ogston. 


Fig.  go. — Macewen's  Operation  for  Genu  Val- 
gum: the  chisel  is  held  in  the  line  for  striking  with 
a  mallet;  the  arrow  shows  the  direction  in  which 
the  chisel  is  levered  up  and  down  so  as  to  make 
a  wide  gap  in  the  bone  (after  Barker). 


angle  with  the  shaft,  half  an  inch  above  the  epiphysis  (JFig. 
89) ;  strike  the  osteotome  several  times  with  a  mallet ;  move 
the  handle  several  times  toward  and  from  the  body,  so  as  to 
widen  the  cut  in  the  bone  (Fig.  90) ;  strike  the  osteotome 
again  several  times,  move  it  again,  and  continue  this  process 
until  the  bone  is  cut  one-third  through.  If  the  osteotome 
becomes  tightly  fixed,  withdraw  it  and  introduce  a  smaller 
one.  When  the  bone  is  cut  two-thirds  through,  withdraw 
the  osteotome,  hold  a  piece  of  wet  antiseptic  gauze  over  the 
opening,  and  fracture  the  femur  by  strong  adduction.     Do 


DISEASES  AXD   IXJURIES   OF  BOXES  AXD  JOIXTS.      473 

not  suture  nor  drain  the  wound,  but  dress  it  antiseptically, 
wrap  the  entire  extremity  in  cotton,  and  apply  a  plaster-of- 
Paris  dressing  up  to  the  groin.  This  dressing  ma}'  be  re- 
moved in  two  weeks,  and  the  patient  may  subsequently  be 
treated  with  sand-bags,  but  without  extension,  as  for  an 
ordinary  fracture  of  the  thigh.  This  operation  is  scarcely 
ever  fatal. 

Ogstoiis  Operation  (Fig.  89). — In  this  operation  the  inter- 
nal condyle  is  sawed  off  obliquely  with  an  Adams  saw — a 
proceeding  which  permits  the  straightening  of  the  knee. 
The  objection  to  this  operation  is  that  it  opens  the  knee- 
joint,  and  that  this  cavity  fills  up  more  or  less  with  a  mixture 
of  blood  and  bone-dust.  Macewen's  operation  is  decidedly 
the  safer. 

Osteotomy  for  a  Bent  Tibia. — In  this  operation  the  in- 
struments required  are  the  same  as  those  indicated  in  the 
above  operation.  The  tibia  is  divided  transversely  or 
obliquely  (linear  osteotomy),  or  a  wedge-shaped  piece  is 
removed  (cuneiform  osteotomy).  The  oblique  incision  is 
the  best.  If  the  convexity  of  the  tibial  curve  is  inward,  cut 
the  bone  from  above  downward  and  from  in  front  backward ; 
if  the  curve  is  forward,  section  the  bone  from  above  down- 
ward and  from  within  outward.  The  fibula  need  rarely  be 
interfered  with. 

Osteotomy  for  Faulty  Ankylosis  of  the  Hip-joint. — 
This  operation  is  performed  in  order  to  allow  straightening 
of  a  limb  which  has  undergone  bony  ankylosis  in  a  faulty 
or  an  inconvenient  position.  In  some  cases  an  attempt  is 
rnade  to  obtain  a  movable  joint,  but  in  most  cases  the  sur- 
geon must  be  satisfied  with  an  ankylosis  in  extension. 
Osteotomy  may  be  performed  through  the  neck  of  the 
femur  or  through  the  shaft  of  the  femur  below  the  tro- 
chanters. 

Osteotomy  throug-h  the  neck  of  the  femur  is  performed 


474  ^   MANUAL    OF  SURGERY. 

(i)  with  a  saw  (Adams's  operation)  or  (2)  with  an  osteo- 
tome. 

1.  AdiXDis's  Operation  (Fig.  91). — In  this  operation  the 
instruments  required  are  a  scalpel,  haemostatic  forceps,  a 
long,  blunt-pointed  tenotome,  and  an  Adams  saw. 

Operation. — The  patient  lies  upon  his  sound  hip ;  the  sur- 
geon  stands  upon  the  side  to  be  operated  upon,  and  back 
of  the  patient.    The  knife  is  entered  a  finger's  breadth  above 
the  great  trochanter,  is  pushed  in   until  it 
*P\    j    strikes  the  neck  of  the  bone,  is  then  carried 
(  >"^     across  the  front  of  and  at  a  rii^ht  anc^le  to 

I  y  the  neck,  and  is  withdrawn,  enlarging  the 

(  /  wound   in  the  soft  parts,  as  it  emerges,  to 

— /  the  extent  of  an  inch.    The  saw  is  now  intro- 

duced   and    the    neck    is    entirely    divided. 
After  the  osteotomy  dress  the  wound  anti- 
l  septically  and  place  the  extremity  straight. 

To    strais^hten    the   limb   it   may  be  found 

Fig.  91. — Osteotomy  "^  •' 

through  the  Neck  of     ncccssary  to   cut   contracted    tendons    and 

the  Femur  :  A,  Adams  s  -^ 

operaiion;   b,  Gant's    fascial  bands.     Apply  the  weight-extension 

operatiozi.  x  i    •  o 

apparatus  and  the  sand-bags.  Begin  passive 
movements  from  the  .start  if  a  movable  joint  is  desired  ;  few 
patients  can  tolerate  the  pain  necessary  to  bring  this  about. 
If  it  is  determined  to  aim  for  a  stiff  joint,  treat  the  case  as  an 
intracapsular  fracture  would  be  treated. 

2.  With  an  Osteotome. — The  instruments  required  in  this 
operation  are  the  same  as  those  used  for  genu  valgum.  No 
sand-bag  is  required.  The  position  of  the  patient  is  the  same 
as  that  in  Adams's  operation.  An  incision  one  inch  long  is 
made,  .starting  just  above  the  great  trochanter,  ascending  in 
the  axis  of  the  femoral  neck,  and  reaching  to  the  bone.  An 
osteotome  is  introduced,  is  turned  to  a  right  angle  with  the 
bone,  and  is  struck  with  a  mallet  until  the  bone  is  completely 
divided.     (It  is  not  to  be  divided  partially  and  then  broken.) 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      475 

The  after-treatment  is  the  same  as  that  for  Adams's  opera- 
tion. The  operation  with  the  osteotome  is  to  be  preferred 
to  that  by  the  saw. 

Osteotomy  of  the  Shaft  of  the  Femur  below  the  Tro- 
chanters (Gant's  Operation). — In  this  operation  (Fig.  91) 
the  saw  may  be  used,  but  the  osteotome  is  to  be  preferred. 
The  instruments  employed  are  the  same  as  those  used  for 
Adams's  operation,  plus  an  osteotome. 

Operation. — The  position  in  Gant's  is  like  that  in  Adams's 
operation.  A  longitudinal  incision  one  inch  long  is  made 
upon  the  outer  aspect  of  the  femur  and  on  a  level  with  the 
lesser  trochanter.  The  osteotome  is  inserted  and  the  bone 
is  completely  divided  below  the  lesser  trochanter.  The 
after-treatment  is  the  same  as  that  for  Adams's  operation. 
Gant's  operation  is  the  best  method  for  correcting  faulty 
position  in  bony  ankylosis,  and  Adams's  operation  can  only 
be  employed  in  those  cases  where  the  femur  still  has  a  neck 
which  practically  is  unchanged. 

Osteotomy  for  Faulty  Ankylosis  of  the  Knee-joint. — 
This  operation  is  performed  for  bony  ankylosis  of  a  knee  in 
a  position  of  flexion.  The  instruments  employed  are  the 
same  as  those  used  for  genu  valgum. 

Operation. — The  patient  lies  upon  his  back  with  his  thighs 
flat  upon  the  bed,  the  legs  hanging  over  the  end  of  the  bed. 
The  surgeon  stands  on  the  patient's  right  side.  Just  above 
the  patellar  articular  surface  upon  the  femur  a  transverse 
incision  is  made,  one  inch  in  length  and  reaching  to  the 
bone.  The  osteotome  is  introduced  and  the  bone  is  cut 
7iearly  through.  The  leg  is  then  forcibly  extended.  Do  not 
extend  too  violently,  or  the  popliteal  vessels  may  be  injured. 
In  cases  where  the  structures  of  the  popliteal  space  are 
tense,  do  not  at  once  bring  the  leg  into  extension,  but  do 
so  gradually  by  means  of  weights.  The  wound  is  dressed 
antiseptically,  and   the   extremity  is  placed  upon  a  double 


4^6  A    MANUAL    OF  SURGERY. 

inclined  plane  and  is  treated  as  for  fracture  near  the  knee- 
joint. 

Osteotomy  for  vicious  union  of  a  fracture  is  performed 
in  case  of  angular  deformity,  and  is  carried  out  in  the  same 
manner  as  are  the  above  procedures.  It  is  best,  when  pos- 
sible, to  enter  the  osteotome  upon  the  concavity  of  the  bent 
bone,  so  as  not  to  rupture  the  periosteum  when  extension  is 
made,  and  to  thus  enable  one  to  gain  a  longer  limb. 

Osteotomy  for  Hallux  Valgus. — In  this  operation  a  linear 
osteotomy  is  made  through  the  neck  of  the  metatarsal  bone 
of  the  great  toe,  the  toe  is  forcibly  adducted,  and  a  splint  is 
applied  to  the  inside  of  the  foot  and  the  toe. 

Osteotomy  for  Talipes  Equino- varus. — ^The  instruments 
required  in  this  operation  are  a  scalpel,  haemostatic  forceps, 
a  narrow,  blunt-pointed  saw,  special  directors,  bone-cutting 
forceps,  sequestrum  forceps,  and  scissors. 

Operation  (after  Barker). — The  patient  lies  upon  his  back, 
the  thigh  is  semiflexed,  the  knee  is  bent,  and  the  sole  of  the 
foot  rests  upon  the  table.  The  surgeon  stands  to  the  right 
side  if  it  is  the  right  limb  operated  upon,  or  to  the  left  side 
if  it  is  the  left  limb.  Feel  for  the  outer  surface  of  the  cuboid 
bone,  and  cut  away  from  over  the  latter  a  piece  of  skin 
corresponding  in  size  with  the  bone-wedge  intended  to  be 
removed  (this  piece  of  skin  must  include  the  bursa  which 
forms  in  these  cases).  Turn  the  foot  outward,  find  the 
astragalo-scaphoid  articulation,  over  which  make  an  incision 
"  from  the  lower  to  the  upper  dorsal  border  of  the  scaphoid 
bone"  (Barker),  reaching  through  the  skin  only;  place  the 
foot  again  in  the  first  position,  raise  all  the  soft  parts  from 
off  the  superior  surface  of  the  tarsus,  and  clear  a  triangular 
surface  corresponding  with  the  base  of  the  wedge  to  be 
removed;  pass  a  "kite-shaped"  director  (Fig.  92)  from  the 
external  wound,  and  cause  it  to  project  from  the  internal 
wound ;  push  the  saw  through  the  groove  of  the  director 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      477 

nearest  the  toes,  and  saw  through  the  tarsus,  from  the  dor- 
sum to  the  sole,  at  right  angles  to  the  metatarsal  bones ; 
push  the  saw  through  the  groove  of  the  director  nearest 
the  ankle,  and  saw  from  the  dorsum  to  the  sole,  at  right 
angles  to  the  long  axis  of  the  calcaneum ;  grasp  the  wedge- 
shaped  piece  of  bone  with  sequestrum  forceps,  and  cut  it 
out  with  scissors,  with  bone-for- 
ceps, or  with  a  blunt  bistoury. 
The  wound  is  well  irrigated,  the 
foot  is  straightened,  the  internal 

wound    is    sewed    up,  the    external  Fig.  g^.-Davy's  Director  (Pye). 

wound  is  sutured  except  at  its  lowest  portion,  where  a  drain- 
age-tube is  to  be  retained  for  twenty-four  hours,  and  the 
wound  is  dressed  antiseptically.  The  foot  is  put  up  in 
plaster  or  is  put  upon  a  Davy  splint. 

Osteotomy  for  Talipes  Equinus. — This  operation  is  de- 
scribed by  Mr.  Davy,  who  devised  it,  as  follows  :  ^  *'  Taking 
the  line  of  the  transverse  tarsal  joint  as  a  guide,  on  the  outer 
and  inner  sides  of  the  foot,  and  immediately  over  the  joint, 
two  wedge-shaped  pieces  of  skin  are  removed,  equal  in  extent 
to  the  amount  of  bone  demanded.  The  soft  structures  are 
freed  on  the  dorsum  of  the  foot  in  the  way  previously 
described ;  but,  as  the  base  of  the  osseous  wedge  for 
equinus  cases  is  at  the  dorsum  and  its  apex  at  the  sole,  the 
parallel  wire  director,  instead  of  the  kite-shaped  varus  one, 
is  used.  The  saw  is  successivelv  inserted  in  its  ejrooves, 
and  by  keeping  in  mind  the  idea  of  a  keystone  a  clean 
wedge  of  bone  is  cut  out  from  the  dorsum  to  the  sole  of 
the  foot."  The  wedge  is  extracted,  and  the  foot  is  straight- 
ened and  is  put  in  plaster  or  in  a  Davy  splint. 

Bone-grafting,  or  Transplantation  (see  p.  303). 

Osteotomy  and  Wiring  for  Ununited  Fracture. — The 
instruments  required  in  this  operation  are  a  scalpel,  haemo- 

*  Barker's  Manual  of  Sitfgical  Operations. 


478 


A   MANUAL    OF  SURGERY. 


static  forceps,  dissccting-forceps,  retractors,  Allis's  dissector, 
an  awl  or  special  drill  (Figs.  93,  94),  chisels,  a  mallet,  a  fine 
saw,  lion-jaw  forceps,  and  silver  wire. 

In  operating,  incise  longitudinally  down  to  the  seat  of 
fracture,  retract  the  periosteum  from  the  bone,  drill  the  bones 
before  cutting  them,  chisel  away  the  material  of  imperfect 
union,  saw  through  each  end  far  enough  from  the  seat  of 
fracture  to  reach  sound  tissue,  pass  large  silver  wires  through 
the  holes  (this  wire  should  be  one-tenth  inch  in  diameter  for 
the  femur,  one-sixteenth  inch  for  the  patella,  etc.),  twist  the 


Fig.  93.— Hamilton's  Improved  Bone-drills. 


Fig.  94. — Wyeth's  Drills,  with  Adjustable  Handle. 

wires  a  fixed  number  of  times  (two)  in  the  direction  that  the 
hands  of  a  watch  move  (this  is  Keen's  direction  in  case 
removal  of  the  wires  should  be  demanded),  sever  the  ends 
of  the  wires,  and  hammer  their  stems  against  the  bone. 
The  wires  may  never  require  removal.  Dress  the  part  as 
a  recent  fracture.  In  fracture  of  the  patella  an  incision  is 
made  in  the  long  axis  of  the  limb,  above  the  middle  of  the 
space  between  the  fragments,  from  well  above  the  upper 
fragment  to  well  below  the  lower  piece ;  this  incision  divides 
all  the  soft  parts.  The  soft  parts  are  retracted,  but  the  peri- 
osteum is  undisturbed;  each  fragment  is  bored  (Fig.  95,  a) 


DISEASES  AND   INJURIES    OF  BONES  AND  JOINTS.      479 


in  one  or  two  places  ;  the  surfaces  of  the  fragments  are  cut 
square  through  sound  bone  with  a  saw ;  all  old  reparative 
material  is  cut  away ;  the  wires  are  passed  through  the  per- 
foration, twisted,  cut  off,  and  hammered  down  as  before 
(Fig.  95,  b).  a  small  drain  is  inserted,  the  wound  is  sutured, 
antiseptic  dressings  are  applied, 
and  the  limb  is  put  upon  a  Mac- 
ewen  splint. 

Treves' s  Operation  for  Caries 
of  the  Lumbar  and  Last  Dorsal 
Vertebrae. — In  this  operation  the 
right  loin  is  chosen  for  incision,  as 
a  rule.  The  instruments  required 
are  a  scalpel,  haemostatic  forceps, 
grooved  director, an  AHis  dissector, 
sequestrum  forceps,  curette  spoons, 
and  a  sand-bag. 

(9A'r^//V;;/.— The  patient  lies   up-         Fio.gs-WiringofthePatella  (after 

-^  r  ir  Barker):   a,  fragments  cul  and  cleaned 

on     his     left     side,     with     the     knees  and  the  wires  passed ;  b,  wires  twisted 

,  111  1  and  hammered  down  upon  the  bone. 

drawn   up  ana  a  sand-bag  under 

him.  The  surgeon  stands  behind  the  patient  (Barker).  An 
incision  is  made  at  the  outer  border  of  the  erector  spinae 
mass,  reaching  from  the  last  rib  to  the  iliac  crest  and  going 
down  at  once  to  the  lumbar  fascia.  The  lumbar  aponeurosis 
is  opened,  the  erector  spinae  is  retracted  inward,  and  the 
anterior  portion  of  the  erector  spinae  sheath  is  incised.  The 
quadratus  lumborum  muscle  is  next  cut,  and  then  the  ante- 
rior leaflet  of  the  lumbar  aponeurosis  is  slit.  Loose  pieces 
of  bone  are  removed  with  forceps,  and  cavities  are  thor- 
oughly curetted.  The  wound  is  irrigated  with  corrosive 
sublimate  and  is  dusted  with  iodoform ;  a  large  tube  is 
inserted  ;  the  wound  is  packed  with  iodoform  gauze,  is 
partly  closed  by  sutures  of  silkworm  gut,  and  is  dressed 
antiseptically. 


48o 


A   MANUAL    OF  SURGERY 


Aspiration  of  Joints. — In  certain  cases  of  joint-effusion 
from  intlamniation,  tubercular  or  otherwise,  and  sometimes 
in  hemorrhage  into  a  joint,  it  is  desirable  to  remove  the  fluid 
by  aspiration.  The  pneumatic  aspirator  is  used  (Fig.  96). 
The  trocar  and  canula  are  thoroughly  asepticized  and  the 
joint  is  prepared  as  for  a  set  operation.  The  needle  is 
entered  at  a  surface  free  from  vessels.  The  directions  for 
using  an  aspirator  are  as  follows :  Insert  the  stopper 
firmly  into  a  strong  bottle  (a  clear  glass  one  preferred),  then 
attach  the  short  elastic  hose  to  the  stop-cock  b  of  the  tube 
projecting  from  the  stopper,  and  attach  the  other  end  of  the 
same  elastic  hose  to  the  exhausting  or  inward-flowing  cham- 


FiG.  96. — Aspirator  and  Injector. 

ber  of  the  pump.  Next  attach  one  end  of  the  longer  elastic 
hose  to  the  stop-cock  A  projecting  from  the  stopper,  and  the 
other  end  to  the  needle.  Care  should  be  taken  that  all  the 
fittings  or  attachments  are  placed  firmly  into  their  respective 
places.  Now  close  the  stop-cock  a  and  open  stop-cock  b, 
and  by  giving  from  thirty-five  to  fifty  strokes  of  the  pump 
a  sufficient  vacuum  can  be  produced  to  fill  with  the  fluid 
from    the   joint  a  bottle    holding    from  a  pint    to  a  quart. 


DISEASES  AND    IXJURIES    OF  BONES  AND  JOINTS.      48 1 

» 

After  having  formed  the  vacuum,  close  the  stop-cock  b,  and 
the  instrument  is  ready  for  use.  The  trocar  may  be  used  to 
inject  corrosive-subhmate  solution,  i  :  1000  (Halstead),  or 
carbolic-acid  solution,  i  :  20.  The  joint  is  dressed  antisep- 
tically  and  is  put  at  rest  upon  splints. 

Excisions  of  Bones  and  Joints. — Excision  or  resection  of 
a  joint  is  the  removal  of  the  articular  portions  of  the  bones 
of  the. joint,  and  also  the  cartilage  and  synovial  membrane. 
In  the  hip-joint  and  shoulder-joint  the  head  of  the  long  bone 
only  may  be  removed,  and  not  the  articular  surfaces  of  both 
bones.  In  excision  enough  bone  is  known  to  have  been  re- 
moved only  when  the  remaining  bone  bleeds.  Excision  of 
a  bone  is  the  removal  of  an  entire  bone  or  of  a  portion  of  it. 
Excision  is  a  conservative  operation  which  often  averts 
amputation. 

Excision  may  be  performed  by  the  open  method,  in  which 
the  periosteum  is  not  preserved,  or  it  may  be  performed  by 
the  subperiosteal  method,  in  which  the  periosteum  is  carefully 
separated  by  a  rugine  and  the  capsular  ligament  is  preserved. 
ArtJirectomy ,  or  evasion,  is  the  excision  of  the  synovial  mem- 
brane of  a  joint. 

Excision  may  be  employed  for  compound  dislocation, 
and  it  is  usually  performed  in  compound  dislocations  of  the 
elbow  and  the  shoulder.  Excisions  for  compound  disloca- 
tions in  other  large  joints  are  very  dangerous  ;  they  should 
not  be  attempted  in  battle-field  practice,  and  are  to  be 
avoided  even  in  civil  practice  unless  the  patient  is  young 
and  vigorous  and  every  advantage  can  be  given  him  during 
the  operation  and  convalescence.  Excision  for  deformity  is 
rarely  performed  except  upon  the  hip,  the  knee,  and  the 
shoulder,  and  these  excisions  must  not  be  employed  if  the 
patient's  condition  leads  one  to  fear  the  result  of  a  protracted 
convalescence.  Excision  of  the  elbow,  however,  is  usually 
a  safe  operation.     In  excising  for  deformity,  always  consider 

31 


482  A   MANUAL    OF  SURGERY. 

the  patient's  trade  and  the  demands  of  habitual  position 
which  it  makes  upon  him.* 

Excision  is  largely  employed  for  joint  disease,  especially 
for  tubercular  joints.  Bell  states  that  attempts  to  preserve 
the  limb  without  excision  are  more  largely  justifiable  in  the 
lower  than  in  the  upper  limbs,  because  operation  in  the  lower 
extremity  is  more  dangerous  than  in  the  upper,  and  because 
a  cure  without  operation  in  the  lower  limbs,  if  this  cure  can 
be  brought  about,  gives  as  good  a  result  as  a  cure  by  ex- 
cision. In  the  upper  extremities  the  danger  from  operation 
is  less  than  is  the  danger  from  waiting.  In  a  young  subject 
an  excision  may  remove  the  epiphysis,  and  thus  lead  to  per- 
manent shortening,  which  is  productive  of  less  inconvenience 
and  deformity  in  the  arm  than  in  the  leg.  The  great  danger 
of  excision  operations  is  that  the  section  may  be  made 
through  cancellous  bony  tissue;  hence  suppuration,  phlebitis, 
myelitis,  septicaemia,  or  pyaemia  may  follow ;  further,  in  ex- 
cision the  cut  is  through  diseased  tissue,  and  a  protracted 
convalescence  is  often  inevitable.  Amputation  is  effected 
through  healthy  tissue,  and  the  convalescence  is  short. 
Excision,  however,  when  successful,  gives  the  patient  a  very 
useful  limb. 

Erasion,  or  Arthrectomy. — Erasion  is  the  complete  ex- 
cision of  diseased  synovial  membrane.  This  operation 
seeks  to  remove  a  depot  of  infection  in  an  early  stage  of 
tubercular  synovitis,  and  it  possesses  the  conspicuous  merit 
of  not  interfering  with  the  epiphysis.  Erasion  is  oftenest 
practised  upon  the  knee-joint.  The  instruments  required  are 
a  scalpel,  haemostatic  forceps,  dissecting  forceps,  toothed 
forceps,  volsellum,  scissors,  bone-gouges,  curettes,  and  an 
Esmarch  apparatus. 

Operation  upon  the  Knee. — The  patient  lies  upon  his  back  ; 
the  limb  is  flexed  with  the  sole  of  the  foot  planted  upon  the 

1  Joseph  Bell,  in  his  Manual  of  Surgical  Operations. 


DISEASES  AND   L\' JURIES   OF  BONES  AND  JOINTS.      483 

table,  and  an  Esmarch  bandage  is  applied  to  a  point  well  up  on 
the  thigh.  The  surgeon  stands  to  the  right  of  the  patient. 
The  incision  starts  in  the  mid-line  of  the  thigh  (on  the  side 
opposite  to  that  occupied  by  the  surgeon),  about  three  inches 
above  the  patella  ;  it  is  carried  down  across  the  ligament  of  the 
patella  and  up  to  a  corresponding  point  on  the  opposite  side 
of  the  thigh.  This  incision  is  made  down  to  the  bone ;  the 
flap  is  turned  up  and  the  joint  exposed ;  the  knee-joint  is 
strongly  flexed,  and  the  synovial  membrane  and  diseased 
ligaments  are  dissected  away  with  scissors  and  forceps,  great 
care  being  taken  that  the  posterior  ligaments  (which,  fortu- 
nately, are  rarely  implicated  early  in  the  case)  are  not  divided 
and  that  the  contents  of  the  popliteal  space  remain  intact. 
After  removing  the  diseased  ligaments  and  synovial  mem- 
brane, examine  the  cartilage  and  remove  any  diseased  por- 
tion, and  then  examine  the  bone  and  gouge  away  any 
tubercular  foci.  Ligate  any  exposed  vessels,  irrigate  the 
wound  and  dust  in  iodoform,  straighten  the  extremity, 
suture  together  the  ends  of  the  ligamentum  patellse,  suture 
the  skin  after  inserting  a  drainage-tube  in  each  angle,  dust 
iodoform  over  the  wound,  and  dress  antiseptically.  Put  the 
limb  upon  a  posterior  splint  for  a  few  days,  then  take  out 
the  drainage-tubes,  re-dress  antiseptically,  and  put  up  in  a 
plaster-of-Paris  dressing,  cutting  trap-doors  upon  each  side 
and  keeping  the  joint  immobile  for  two  or  three  weeks.  This 
operation  is  only  suited  to  early  cases,  in  which  it  gives  a 
good  result,  some  capacity  for  motion  being  not  unusually 
preserved. 

Excision  of  the  Shoulder-joint. — In  the  shoulder-joint 
/rt:;'//Vr/ excision  is  often  performed,  the  head  of  the  humerus 
being  removed  and  the  glenoid  being  undisturbed ;  but  some 
patients  require  complete  excision,  the  entire  glenoid  depres- 
sion, as  well  as  the  head  of  the  humerus,  being  removed  by 
the   surgeon.      Excision  of  the  shoulder-joint  is  made,  if 


484  A    MANUAL    OF  SURGERY. 

possible,  an  intracapsular  operation,  the  capsule  being 
opened,  but  the  capsular  attachment  to  the  anatomical 
neck  not  being  interfered  with.  In  bad  cases,  however,  the 
capsular  attachment  must  be  destroyed.  This  operation  is 
rare  in  civil,  but  is  common  in  military  practice ;  it  is  per- 
formed in  gunshot  wounds,  in  compound  dislocations,  in 
tubercular  disease,  and  in  tumors  of  the  head  and  upper  por- 
tion of  the  humerus.  The  instruments  required  are  a  scalpel, 
an  Adams  saw,  an  osteotome  or  chisel,  a  mallet,  an  Allis 
dissector,  a  periosteum-elevator,  haemostatic  forceps,  dissect- 
ing-forceps,  toothed  forceps,  lion-jawed  forceps,  sequestrum 
forceps,  metal  retractors,  curettes,  and  cutting  bone-forceps. 
Operation  by  Anterior  Incision. — The  patient  lies  supine ; 
a  pillow  is  placed  benea-th  the  shoulders,  and  a  sand  pillow 
is  put  beneath  the  shoulder  to  be  operated  upon.  The  arm 
is  held  to  the  side  with  the  outer  condyle  forward  and  the 
bicipital  groove  inward  (Barker's  directions).  The  surgeon 
stands  upon  the  affected  side.  An  incision  three  or  four 
inches   in  length  is  made  from  just  external  to   the  cora- 

FiG.  97. — i-io.  Amputations  :  i,  of  lower  third  of  forearm  (Teale's) ;  2,  at  shoulder-joint 
by  large  postero-external  flap  fsecond  method);  3,  at  shoulder-joint  by  triangular  flap  from 
deltoid  (third  method);  4,  5,  through  tarsus  (Chopart's) ;  6,  7,  at  knee-joint;  8.  by  single 
flap  (Garden's) ;  9,  10,  of  thigh  (Teale's).  a,  excision  of  hip;  b,  of  ankle-joint  (Hancock's 
incision). 

Fig.  98. — 1-18,  Amputations  :  i,  amputation  at  wrist-joint  (dorsal  incision) ;  2,  at  wrist- 
joint  (palmar  incision);  3,  at  forearm  (dorsal  incision);  4,  at  forearm  (palmar  incision);  5, 
at  elbow-joint  (anterior  flap);  6,  at  arm  (Teale's);  7,  at  shoulder-joint  (first  method);  8,9, 
of  metatarsus  (Key's);  10,  11,  at  ankle  (Syme's)  ;  12,  13,  of  leg,  posterior  flap  (Lee's)  ;  14, 
at  knee-joint  (Garden's) ;  15,  of  thigh  (B.  Bell's) ;  16,  of  thigh  rSpence's'* ;  17,  of  thigh  in  mid- 
dle third;   18,  at  hip-joint,     a,  excision  of  wrist  (radial  incision) ;   b,  of  wrist  (ulnar  incision). 

Fig.  99. — 1-9,  Amputations  :  i,  of  arm  by  double  flaps  :  2,  at  shoulder-joint ;  3,  at  ankle- 
joint  by  internal  flap  (Mackenzie's) ;  4,  5,  of  leg  just  above  the  ankle-joint  (Syme's) ;  6,  7, 
below  the  knee  (modified  circular)  ;  8,  through  condyles  of  femur  (Syme) ;  9,  at  lower  third 
of  thigh  (Syme).     a,  excision  of  head  of  humerus ;  b,  of  knee-joint  (semilunar  incision). 

Fig.  100. — 1-8,  Amputations  :  i,  at  elbow-joint  (posterior  flap) ;  2,  at  shoulder-joint,  pos- 
terior incision  (first  method)  ;  3,  at  ankle-joint  (Mackenzie's)  ;  4,  through  condyles  of  femur 
(Syme);  5,  at  lower  third  of  thigh  (Syme);  6,  at  knee  (posterior  incision);  7,  of  thigh 
(Spence's) ;  8,  at  hip-joint,  a-g,  Excisions:  a,  excision  of  shoulder-joint  (deltoid  flap) ;  b, 
of  shoulder-joint  (posterior  incision) ;  c,  of  elbow-joint  (H -shaped  incision) ;  D,  of  elbow-joint 
(linear  incision) ;  e,  of  hip-joinl  (Gross's);  F,  of  os  calcis;  g,  of  scapula. 


DISEASES  AXD   INJURIES   OF  BONES  AND  JOINTS.      485 


Fig.  99. 


Fig.  100. 


Amputations  and  Excisions  (Joseph  Bell  ;  see  p.  484). 


486  A   MANUAL    OF  SURGERY. 

coid  process,  running  straight  down  the  humerus  (Fig. 
99,  a).  This  incision  divides  the  border  of  the  deltoid 
muscle  and  brings  into  sight  the  long  head  of  the  biceps. 
The  tendon  of  the  biceps  is  retracted  inward,  unless  it  is  dis- 
eased, in  which  case  it  is  resected.  The  knife  is  carried  up 
the  groove  and  opens  the  capsule  of  the  joint.  The  peri- 
osteum is  lifted  from  the  neck  of  the  bone  while  an  assistant 
rotates  the  elbow  to  make  the  muscles  tense.  In  some 
places,  if  the  periosteum  tears,  muscular  insertions  must  be 
cut  with  a  knife.  The  head  of  the  bone  is  sawn  off  while 
the  bone  is  in  place,  or  the  elbow  is  strongly  pulled  back, 
the  head  of  the  bone  is  forced  out  of  the  wound,  and  is  then 
sawn  off  at  the  point  required.  In  ordinary  cases,  remove 
only  the  articular  head ;  in  other  cases  make  the  section  just 
above  the  surgical  neck  ;  in  yet  others  remove  a  portion  of 
the  shaft.  If  the  glenoid  cavity  is  found  diseased,  any  dead 
bone  must  be  removed  by  the  chisel  and  mallet  or  by  the 
cutting- forceps.  Scrape  away  all  damaged  tissue;  ligate 
bleeding  points ;  irrigate  the  wound  with  corrosive-sub- 
limate solution  ;  swab  it  out  with  a  solution  of  chloride  of 
zinc  (gr.  xx  to  .Ij) ;  dust  with  iodoform  ;  close  the  upper 
portion  of  the  wound  and  insert  a  drainage-tube  in  the 
lower  angle ;  dress  the  wound  antiseptically ;  place  a  small 
pad  in  the  axilla ;  apply  the  second  roller  of  Desault ;  and 
put  the  patient  in  bed  with  a  pillow  under  the  affected 
shoulder.  In  seven  days  the  hand-sling  is  substituted  for 
the  bandage,  and  with  the  elbow  hanging  free  the  patient  is 
permitted  to  get  up  and  is  advised  to  move  his  arm  fre- 
quently. Drainage  is  maintained  until  the  wound  is  well 
healed  from  the  bottom. 

Excision  by  the  deltoid  flap  is  performed  when  the  head 
of  the  bone  is  much  enlarged  (as  by  a  tumor)  or  when  the 
tissues  are  thick  and  indurated.  The  deltoid  flap  is  in 
the  shape  of  a  V  or  is  semilunar  (Fig.  lOO,  a).     Raising  this 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      48/ 

flap  exposes  the  head  of  the  bone  most  satisfactorily.  Bell 
states  that  when  the  glenoid  cavity  is  chiefly  involved  the 
incision  should  be  posterior  (Fig.  100,  a). 

Excision  of  the  Elbow-joint. — This  operation  is  per- 
formed for  wounds,  faulty  ankylosis,  and  chronic  articular 
disease.  Excision  must  be  complete.  Endeavor  to  make 
a  subperiosteal  resection  ;  this  maintains  the  shape  of  the 
articulation  and  gives  the  best  chance  for  a  movable  joint. 
The  instruments  used  are  the  same  as  those  for  the  shoulder, 
plus  a  Butcher  saw. 

Operation. — The  patient  is  "  supine,  but  inclining  to  the 
sound  side,  the  affected  arm  being  held  almost  vertical,  with 
the  forearm  flexed  and  nearly  horizontal  "  (Barker).  The 
incision  is  made  on  the  posterior  surface  of  the  joint.  A 
single  posterior  incision  is  usually  employed  (Fig.  100). 
An  incision  is  made  a  little  internal  to  the  long  axis  of  the 
olecranon,  and  reaching  two  inches  above  and  two  inches 
below  the  tip  of  the  olecranon.  This  incision  goes  down  to 
the  bone,  and  throughout  the  entire  operation  the  surgeon 
must  guard  and  shield  the  ulnar  nerve.  The  periosteum 
and  soft  parts  are  well  separated  ;  the  olecranon  is  sawn  off; 
forced  flexion  exposes  the  joint-cavity  freely,  and  enables 
the  surgeon  to  lift  the  periosteum  and  soft  parts  from  the 
humerus;  the  humerus  is  sawed  through  at  the  beginning 
of  its  condyloid  processes  ;  the  radius  and  ulna  are  cleared 
and  are  sawn  at  a  level  below  that  of  the  base  of  the  coro- 
noid  process  of  the  ulna.  Cut  and  spoon  away  diseased 
tissues,  the  wound  being  irrigated,  closed,  drained,  and  dressed. 
In  some  cases  an  H-shaped  incision  is  employed  (Fig.  100,  c), 
but  the  cicatrix  of  a  transverse  cut  will  limit  flexion  of  the 
limb. 

After  excision  of  the  elbow  the  patient  is  put  to  bed  and 
the  arm  is  laid  upon  a  pillow,  the  elbow  being  placed  mid- 
way between  a  right  angle  and  complete  extension,  the  fore- 


488 


A   MANUAL    OF  SURGERY. 


arm  being  placed  midway  between  pronation  and  supination. 
No  splint  is  used,  as  a  rule.  The  aim  in  treatment  is  to  obtain 
a  freely-movable  joint.     Passive  motion  is  begun  in  one  week, 


Fig.  ioi. — Esmarch's  bpliiu  for  Excision  of  Elbow. 

when  the  patient  gets  up.  The  hand  is  carried  for  a  time  in 
a  sling.     Esmarch  used  the  splint  shown  in  Figure  lOi. 

Excision  of  the  Wrist-joint. — Bell  states  that,  whatever 
method  of  excision  is  chosen,  three  cardinal  rules  must  be 
borne  in  mind  :  (i)  Remove  all  the  diseased  bone,  including 
the  portions  of  the  radius,  ulna,  carpus,  and  metacarpus  which 
are  covered  with  cartilage  ;  (2)  interfere  with  the  tendons  to 
the  least  possible  degree  ;  and  (3)  begin  passive  motion  of 
the  fingers  very  early.  Many  surgeons  prefer  the  simple 
gouging  away  of  diseased  foci  and  the  scraping  of  sinuses 
instead  of  a  formal  resection  of  the  wrist,  amputation  being 
employed  in  severe  cases  or  when  scraping  fails  after  several 
trials.  Formal  excision  is  not  very  often  done,  and  the 
results  cannot  often  be  considered  as  very  favorable. 

Lister's  Open  Metliod  of  Excision. — The  instruments  re- 
quired in  this  operation  are  the  same  as  those  used  for  any 
resection.  Break  up  adhesions  as  completely  as  possible  by 
forcible  movements.  Apply  a  tourniquet  or  an  Esmarch  appa- 
ratus. The  patient  lies  upon  his  back,  the  arm  and  the  fore- 
arm being  brought,  from  stage  to  stage,  into  the  most  desirable 
positions.     Begin  an  incision  over  the  middle  of  the  dorsum 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      489 

of  the  radius,  on  a  level  with  the  styloid  process ;  carry  it 
downward  in  the  direction  of  the  inner  edge  of  the  articula- 
tion of  the  thumb  with  its  metacarpal  bone,  and  when  the 
knife  reaches  the  radial  side  of  the  second  metacarpal  bone, 
alter  the  direction  of  the  incision  and  carry  it  downward  in 
the  long  axis  of  the  metacarpal  bone  to  about  its  middle 
(Fig.  98,  a).  This  is  known  as  the  radial  incision^  and  the 
only  tendon  divided  is  that  of  the  extensor  carpi  radialis 
brevior  muscle.  The  tissues  upon  the  radial  aspect  of  the 
incision  are  dissected  up,  the  tendon  of  the  extensor  carpi 
radialis  longior  muscle  is  divided  at  its  point  of  insertion 
(Bell),  and  all  the  soft  structures  are  retracted  outward, 
exposing  the  trapezium,  which  is  cut  off  from  the  rest  of  the 
carpus,  but  which  is  left  in  place,  as  its  removal  at  this  stage 
endangers  the  radial  artery  (Barker).  By  extending  the 
hand  the  tendons  are  loosened  and  the  carpus  is  cleared  in 
the  direction  of  the  ulnar  border  of  the  hand. 

Another  incision  is  made,  starting  upon  the  inner  surface 
of  the  wrist,  two  inches  above  the  articular  surface  of  the 
ulna,  and  midway  between  the  ulna  and  the  flexor  carpi 
ulnaris  tendon.  This  incision,  which  is  known  as  the  ubiar 
incision,  is  carried  down  until  it  is  opposite  the  middle  of 
the  fifth  metacarpal  bone  in  the  palm  (Fig.  98,  b).  "The 
dorsal  lip  of  this  incision  is  raised  "  (Bell),  and  the  extensor 
carpi  ulnaris  tendon  is  divided  and  dissected  from  its  depres- 
sion, but  is  not  separated  from  the  integument.  The  extensor 
tendons  are  lifted  up  ;  the  ligaments  upon  the  dorsum  and 
sides  of  the  wrist-joint  are  cut ;  the  flexor  tendons  are  lifted 
from  the  carpal  bones ;  the  pisiform  bone  is  cut  from  the 
carpus,  but  is  not  yet  removed ;  and  the  unciform  process  of 
the  unciform  bone  is  cut  with  forceps.  The  anterior  radio- 
carpal ligament  is  divided,  the  carpo-metacarpal  articulations 
are  cut  through,  and  the  carpus  is  pulled  out  with  bone- 
forceps.     The  ends  of  the  radius  and  ulna  are  forced  out  of 


490 


A   MANUAL    OF  SURGERY. 


the  ulnar  incision.  All  that  portion  of  the  ulna  which  is 
crusted  with  cartilage  is  to  be  removed,  the  saw-cut  is  to  be 
oblique,  and  the  base  of  the  styloid  process  is  to  be  left 
behind.  A  thin  section  is  to  be  sawn  from  the  radius,  and 
the  tendon-grooves  are  not  to  be  impinged  upon.  The  artic- 
ular surface  of  the  ulna  is  cut  away  with  pliers  (Bell).  If 
foci  of  disease  are  discovered  beyond  these  points,  they  are 
to  be  gouged  out.  The  ends  of  the  metacarpal  bones  are 
sawn  off,  and  their  articular  facets  are  cut  away  by  means 
of  pliers.  The  trapezium  is  dissected  out,  the  end  of  the 
first  metacarpal  bone  is  sawn  off  and  its  facet  is  cut  away 
with  pliers,  and  a  portion  of  the  pisiform  bone  is  removed 
(the  entire  bone  being  removed  if  it  be  diseased).  The 
wound  is  irrigated,  vessels  are  tied,  the  radial  incision  is 
closed,  the  ulnar  incision  is  partly  closed,  a  drainage-tube 
is  inserted  by  way  of  the  ulnar  incision,  the  wounds  are 
dressed  antiseptically,  and  the  Esmarch  apparatus  is  taken 
off  The  forearm  and  hand  are  placed  upon  a  splint  which 
immobilizes  the  wrist  and  leaves  the  fingers  semiflexed.    The 


Fig.  I02. — Esmarch's  Interrupted  Splint  Applied. 


splint  is  worn  for  many  months,  until  the  wrist-joint  is  immo- 
bile and  solid.  Esmarch  uses  the  splint  shown  in  Figure  102. 
Passive  motion  of  the  fingers  is  begun  after  thirty-six  hours. 
Excision  of  Metacarpal  Bones  and  of  Phalang-es. — 
Excision  of  a  metacarpal  bone,  except  in  cases  of  necro- 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      49 1 


sis  with  the  formation  of  large  quantities  of  new  bone, 
usually  leaves  a  useless  finger ;  hence  amputation  is  pre- 
ferred usually  to  excision.  This  rule  does  not  apply  to 
the  metacarpal  bone  of  the  thumb,  which  is  occasionally 
resected.  The  incision  for  this  operation  is  made  upon  the 
dorsum,  and  is  straight.  Excision  of  the  proximal  phalanx 
of  the  thumb  is  sometimes  performed.  Excision  for  disease 
is  rarely  performed  upon  the  finger-joints,  amputation  being 
preferred,  though  the  operation  is  sometimes  undertaken  for 
compound  dislocation.  In  the  metacarpo-phalangeal  joint 
of  the  thumb,  excision,  if  it  can  be  performed,  is  preferred 
to  amputation.  The  incision  for 
resection  of  this  joint  is  placed 
upon  the  radial  aspect. 

Excision  of  the  Hip-joint. — 
Some  surgeons  advocate  this  op- 
eration; others,  notably  Marsh,  are 
emphatically  opposed  to  it.  Ex- 
cision should  be  performed  in  the 
early  stage  of  tubercular  disease  if 
less  radical  treatnicnt  has  failed, 
and  in  this  stage  the  usual  position 
of  the  limb  is  one  of  flexion,  ab- 
duction, and  eversion.  In  cases  of 
long  duration,  especially  where  dis- 
location exists,  excision  is  an  easy 
and  a  comparatively  safe  operation ; 
in  recent  cases  it  is  difficult  and 

•,i        'i.       J        •   1     J       J  femoris  muscle;   c,  sartorius  muscle; 

carries    with    it    decided    dangers,         ^   .     .    .'.  ' 

•^  '     D,  anterior  incision. 

but   the   peril   cf  delay   is  greater 

than  is  the  peril  of  an  early  resection.  In  cases  of  hip 
disease  with  involvement  of  the  acetabulum  the  mortality 
is  fifty  per  cent.,  whether  operation  is  or  is  not  attempted. 
Excision  is  performed  especially  for  tubercular  disease  and 


Fig.  103. — Excision  of  the  Hip-joint : 
,  gluteus   muscle  ;    b,  tensor  vaginae 


492  A    MANUAL    OF  SURGERY. 

for  gunshot  injuries  (Fig.  103).    The  instruments  required  are 
those  used  for  other  excisions. 

Operation  by  Anterior  Incision  (Parker's  Operation). — In 
this  operation  the  patient  is  supine,  with  the  thighs  extended 
as  thoroughly  as  circumstances  permit.  The  surgeon  stands 
to  the  right  of  the  patient.  An  incision  is  begun  half  an 
inch  below  and  half  an  inch  external  to  the  anterior  superior 
iliac  spine,  and  it  is  carried  downward  and  a  little  inward 
for  about  three  inches  (Fig.  103,  d).  If  dislocation  exists,  the 
incision  must  not  be  so  long.  This  incision  is  carried  at 
once  deeply  between  the  muscles,  and  the  capsule  of  the 
joint  is  opened.  The  neck  of  the  bone  is  divided  from  its 
upper  surface  downward  with  a  saw  or  an  osteotome,  and 
without  dislocating  the  bone  through  the  wound  by  forcible 
extension  and  eversion.  The  head  of  the  bone  is  removed. 
All  tubercular  foci  are  scraped  away,  and  the  gouge  is  used 
upon  tubercular  areas  of  the  acetabulum.  All  sinuses  are 
most  thoroughly  scraped.  Bleeding  is  arrested,  the  wound 
is  irrigated  with  corrosive-sublimate  solution,  mopped  out 
with  chloride-of-zinc  solution,  and  dusted  with  iodoform. 
A  drainage-tube  is  inserted  at  the  lower  angle  of  the  incision, 
and  the  upper  portion  of  the  cut  is  closed.  The  wound  is 
dressed  antiseptically.  Extension  is  made  with  the  extension 
apparatus  until  healing  has  obtained  a  good  headway,  when 
a  double  Thomas  splint  is  applied,  so  that  the  patient  can 
be  taken  out  daily  in  the  air  and  sunlight.  Seek  to  obtain 
a  movable  joint  by  passive  motions.  This  joint  will,  how- 
ever, rarely  be  very  firm. 

Operation  by  Lateral  Incision. — In  this  operation  a  straight 
incision  two  inches  long  is  made  in  the  direction  of  the  axis 
of  the  femur,  and  runs  downward  from  the  apex  of  the  great 
trochanter.  From  the  beginning  of  this  incision  a  curved 
incision  is  carried  toward  the  head  of  the  bone,  the  convex- 
ity of  the  curve  being  backward  (Fig.  97,  a).     Bell  advises 


DISEASES  AND   INJURIES   OF  BONES  AND  JOINTS.      493 

the  use  of  the  saw  after  bringing  the  head  of  the  bone  into 
the  wound  by  adduction  and  eversion  of  the  thigh.  Barker 
apphes  the  saw  with  the  bone  /;/  situ,  and  strongly  opposes 
wrenching  the  bone  out  of  the  incision,  because  of  the 
danger  of  peehng  off  the  periosteum,  which  peehng,  if  it 
takes  place,  favors  necrosis. 

Incision  of  Gross, — In  Gross's  operation  a  semilunar  flap 
is  made  with  the  convexity  backward  (Fig.  100,  e). 

Excision  of  the  Knee-joint. — In  this  operation  a  com- 
plete excision  should  be  performed,  and  the  patella  ought  to 
be  removed.  This  operation  is  performed  in  tubercular  dis- 
ease, in  some  compound  fractures  and  compound  dislocations, 
and  in  some  cases  of  angular  ankylosis,  but  it  is  not  suitable 
for  gunshot  injuries,  amputation  being  advisable  (Ashurst). 
The  instruments  required  are  the  same  as  those  for  the 
shoulder,  plus  Butcher's  saw. 

Operation  by  Anterior  Semilunar  Flap. — The  patient  lies 
upon  his  back,  and  the  joint,  if  not  ankylosed  in  extension, 
is  semiflexed.  The  surgeon  stands  to  the  right  side.  An 
incision  is  made,  at  once  opening  the  joint,  starting  from  one 
condyle  and  reaching  the  other  cond\'le  by  a  downward 
curve  which  passes  through  the  ligamentum  patella  midway 
between  the  tuberosity  of  the  tibia  and  the  inferior  margin 
of  the  patella  (Fig.  99,  b).  The  flap  is  dissected  up,  the 
knee  is  thrown  into  forced  flexion,  the  lateral  ligaments  and 
crucial  ligaments  are  cut,  and  the  end  of  the  femur  is  well 
cleared.  The  blade  of  Butcher's  saw  is  passed  beneath  the 
bone,  which  is  sawn  from  below  upward  (Ashurst).  The 
end  of  the  tibia  is  cleared  and  a  portion  is  sawn  off  If, 
after  sawing,  diseased  foci  are  discovered,  another  section 
can  be  sawn  off  or  the  foci  can  be  gouged  away.  Prof 
Ashurst,  who  is  one  of  the  highest  of  authorities,  insists 
that  in  sawing  through  the  femur  the  natural  obliquity  of 
the  bone  must  be  borne  in  mind  and  the  section  must  be 


494  A   MANUAL    OF  SURGERY. 

made  in  "  a  line  parallel  to  that  of  the  free  surface  of  the 
condyles."  If  the  section  is  made  transverse  to  the  axis 
of  the  femur,  "the  limb,  after  adjustment,  will  be  found  to 
be  markedly  bowed  outward."  Ashurst  says  that  the  epi- 
physeal line  is  somewhat  higher  on  the  front  than  it  is  on 
the  back  of  the  femur,  and  in  consequence  the  following 
rule  is  formulated  for  section  of  the  condyles :  The  section 
of  the  condyles  should  be  "  in  a  plane  which,  as  regards  the 
axis  of  the  femur,  is  oblique  from  behind  forward,  from 
below  upward,  and  from  within  outward."  Ashurst  advo- 
cates section  of  the  tibia  "  in  a  plane  transverse  to  the  long 
axis  of  the  bone,  with  a  slight  antero-posterior  obliquity,  so 
as  to  correspond  with  that  of  the  section  of  the  condyles." 
Ashurst  says  also  that  the  patella  must  be  removed,  whether 
it  is  diseased  or  not,  and  he  quotes  Peniere's  observations  to 
the  effect  that  excision  of  the  patella  diminishes  the  risk  of 
death  one-third,  and  its  retention  doubles  the  chance  of  re- 
covery without  a  future  amputation. 

After  removing  the  patella  the  diseased  synovial  membrane 
is  clipped  away  with  scissors  and  all  sinuses  and  diseased 
territories  are  well  curetted.  The  posterior  ligament  of  the 
joint  is  not  removed  unless  it  is  diseased  ;  its  retention  pre- 
vents displacement  and  guards  the  popliteal  space.  In  chil- 
dren the  fragments  should  be  wired  together;  in  adults  this 
need  not  be  done.  After  haemostasis  irrigate,  dust  with  iodo- 
form, insert  a  drainage-tube,  suture,  dress  antiseptically,  and 
adjust  the  limb  upon  Price's  splint  or  Ashurst's  bracketed  wire 
splint.  In  some  cases  tenotomy  is  required  to  permit  exten- 
sion. If  the  bracketed  splint  is  used,  place  it  in  a  fracture-box. 
If  the  femur  tends  to  project  anteriorly,  use  an  anterior  splint. 
If  there  be  a  tendency  to  outward  bowing,  adopt  Ashurst's 
expedient  of  carrying  a  strip  of  adhesive  plaster  around  the 
outside  of  the  limb  and  fastening  it  to  the  inner  side  of  the 
splint.     The  splint  is  kept  on  until  bony  union  is  complete, 


DISEASES  AND   INJURIES    OF  BONES  AND  JOINTS.      495 

as  in  this  operation  a  movable  joint  is  never  sought.  Many 
surgeons  use  a  plaster-of-Paris  spHnt  which  is  apphed  when 
heahng  is  well  advanced  (Fig.  104). 


Fig.  104. — Watson's  Plaster-of-Paris  Swing-splint. 

Excision  of  the  Ankle-joint. — This  operation  is  performed 
chiefly  in  gunshot  wounds,  in  compound  dislocations,  and  in 
early  cases  of  chronic  joint  disease.  Complete  resection  is 
employed  for  chronic  joint  disease.  Excision  of  the  ankle 
is  a  rare  operation.  The  instruments  used  are  the  same  as 
those  employed  for  any  resection. 

Operation  (Hancock's  Method). — In  this  operation  the  pa- 
tient lies  upon  his  back  and  the  foot  rests  upon  its  inner  side. 
The  surgeon  stands  on  the  outer  side  of  the  damaged  limb. 
Begin  an  incision  just  behind  and  two  inches  above  the 
external  malleolus,  and  carry  it  across  the  front  of  the  joint 
to  a  corresponding  point  above  and  behind  the  internal 
malleolus  (Fig.  97,  b)  ;  this  incision  goes  only  through 
the  skin,  and  the  flap  thus  marked  out  is  reflected.  "  Cut 
down  upon  the  external  malleolus,  carrying  the  knife  close 
to  the  edge  of  the  bone  both  behind  and  below  the  process, 
dislodge  the  peronei  tendons,  and  divide  the  external  lateral 
ligaments"  (Joseph. Bell).  Cut  the  fibula  one  inch  above  the 
malleolus  by  means  of  pliers ;  divide  the  tibio-fibular  liga- 


496 


A   MANUAL    OF  SURGE KV. 


ment ;  turn  the  foot  upon  its  outer  side ;  dissect  from  their 
habitat  back  of  the  inner  malleolus  the  tendons  of  the  pos- 
terior tibial  and  the  common  flexor  of  the  toes ;  carry  the 
knife  around  the  inner  malleolus,  close  to  the  bony  edge ; 
separate  the  internal  lateral  ligament,  and  dislocate  the  lower 
end  of  the  tibia  through  the  wound  by  turning  the  sole  of 
the  foot  downward ;  saw  off  the  lower  end  of  the  tibia  and 
the  articular  process  of  the  astragalus,  sawing  away  from  the 
tendo  Achillis,  and  remove  the  fragments  with  bone-forceps. 
Cut  away  diseased  synovial  membrane,  and  curette  all 
sinuses   and    tubercular   areas.      Arrest    bleeding,    irrigate, 


Fig.  105. — Volkmann's  Dorsal  Splint  for  Excision  of  the  Ankle. 


and  drain.  Sew  up  the  wound,  insert  a  tube  at  its  outer 
angle,  and  pull  it  out  at  the  inner  angle.  Apply  antiseptic 
dressings,  and  put  up  the  foot  in  fixed  dressing  or  in  splints 
at  a  right  angle  to  the  leg  (Fig.  105).  In  Langenbeck's 
operation  the  excision  is  subperiosteal.  If,  in  an  excision 
of  the  ankle-joint,  the  astragalus  is  found  extensively  dis- 
eased, remove  the  entire  bone. 

Excision  of  the  Os  Calcis. — In  caries  limited  to  the  os  cal- 
cis  most  surgeons  prefer  to  gouge  away  the  dead  bone,  leav- 
ing the  periosteum  and,  if  possible,  a  shell  of  healthy  bone, 
and  draining  thoroughly.    Others  advocate  excision  in  some 


DISEASES  AND   INJURIES    OF  BO.XES  AMD  JOIXTS.      497 

cases.  Extensive  disease  limited  purely  to  the  os  calcis  is 
rare,  and  most  surgeons  advise  gouging  for  limited  caries, 
and  Syme's  amputation  in  event  of  the  disease  extending 
be\'ond  the  periosteum  or  reaching  adjacent  bones. 

Operation  by  Subperiosteal  Method. — In  this  operation  the 
position  assumed  by  the  patient  is  supine  with  the  leg 
extended  and  the  foot  resting  on  its  inner  side.  The 
incision,  which  cuts  the  tendo  Achillis  and  reaches  the  bone 
at  once,  is  begun  at  the  upper  border  of  the  os  calcis  and 
the  inner  margin  of  the  tendo  Achillis,  and  is  taken  outward 
and  horizontally  forward  to  a  point  in  front  of  the  calcaneo- 
cuboid articulation.  A  vertical  incision  is  begun  near  the 
forward  termination  of  the  initial  incision,  is  carried  across 
the  outer  edge  and  plantar  surface  of  the  foot,  and  terminates 
at  the  external  margin  of  the  inner  surface  of  the  os  calcis. 
Some  surgeons  carry  the  vertical  incision  a  little  upward, 
toward  the  dorsum  (Fig.  100,  f).  The  periosteum  is  entirely 
stripped  with  an  elevator,  the  os  calcis  is  removed,  the  cavity 
is  packed  with  iodoform  gauze,  the  wound  is  stitched,  a  drain 
is  inserted  posteriorly,  and  the  foot  is  dressed  antiseptically 
and  put  up  in  plaster  at  a  right  angle  to  the  leg,  trap-doors 
being  cut  for  drainage. 

Excision  of  the  astragalus  is  a  rare  operation. 

Operation  by  the  Subperiosteal  Plan. — Barker  advises  an 
incision  going  at  once  to  the  bone,  from  the  "  tip  of  the  ex- 
ternal malleolus  forward  and  a  little  inward,  curving  toward 
the  dorsum  of  the  foot."  The  foot  is  extended  and  turned 
inward,  the  periosteum  is  lifted,  the  bone  is  removed,  and 
the  wound  is  treated  and  the  foot  is  dressed  as  is  done  in 
excision  of  the  os  calcis. 

Excision  of  the  Metatarso-phalangeal  Articulation  of 
the  Big"  Toe. — In  this  operation,  make  a  lateral  incision  and 
cut  off  or  saw  off  the  proximal  end  of  the  first  phalanx  and 
the  distal  third  of  the  first  metatarsal  bone. 

32 


498  A   MANUAL    OF  SURGERY. 

Excision    of    the    Metatarsal    Bone    of   the    Big-   Toe 

(Butcher's  Method). — In  this  operation  a  lateral  straight 
incision  is  made,  the  periosteum  is  elevated,  and  the  shaft  is 
sawn  from  each  extremity  and  removed. 

Excision  of  the  clavicle  may  be  required  in  dislocation, 
in  caries,  in  necrosis,  for  gunshot  wounds,  in  tumor  of  this 
bone,  as  a  preliminary  to  ligation  of  the  artery  and  vein  in 
certain  cases  of  amputation  at  the  shoulder-joint,  or  in  cases 
of  removal  of  the  entire  upper  extremity.  In  excision 
of  the  clavicle  the  position  of  the  patient  is  the  same  as 
that  for  ligation  of  the  third  part  of  the  subclavian  artery 
(p.  277).  An  incision  is  made  down  to  the  bone,  from  the 
sterno-clavicular  joint  to  the  acromio-clavicular  articulation. 
If  the  case  is  suitable,  the  periosteum  is  stripped  and  the 
bone  is  sawn  and  removed  ;  if  not,  the  bone  is  sawn  and 
each  half  is  separately  disarticulated.  The  wound  is  sutured 
and  dressed,  and  the  limb  is  put  up  in  a  Velpeau  bandage. 

Excision  of  the  Scapula. — Complete  excision  of  the 
scapula  is  most  usually  performed  for  tumors.  Partial  ex- 
cision requires  no  detailed  description,  as  it  resembles  the 
operation  of  sequestrotomy.  In  excision  of  the  scapula 
the  patient  lies  upon  his  sound  side.  Treves  suggests 
the  following  incisions :  One  outside  the  vertebral  border 
of  the  scapula,  from  its  superior  to  its  inferior  angle ; 
another  from  over  the  acromio-clavicular  joint,  along  the 
acromion  process  and  spine  of  the  scapula  to  meet  the 
first  incision.  Syme  used  an  incision  carried  transversely 
inward  from  the  acromion  process  to  the  vertebral  border 
of  the  scapula,  and  another  cut  directly  downward  from 
the  centre  of  the  first  incision  (Fig.  lOO,  g).  In  the 
method  of  Treves  ^  the  upper  flap  is  reflected  and  the 
trapezius  muscle  is  divided ;  the  lower  flap  is  reflected  and 

1  Treves's  Manual  of  Operative  Surgery,  one  of  the  very  best  books  now 
before  the  profession. 


DISEASES  AND   INJURIES    OF  BONES  AND  JOINTS.      499 

the  deltoid  muscle  is  divided.  The  patient's  hand  is  placed 
on  the  sound  shoulder;  the  muscles  of  the  vertebral  border 
are  divided,  the  posterior  scapular  artery  is  tied,  and  while 
the  vertebral  border  of  the  scapula  is  pulled  toward  the 
surgeon  the  serratus  magnus  muscle  is  cut,  the  upper  border 
of  the  shoulder-blade  is  cleared,  and  the  suprascapular  artery 
is  tied.  The  hand  is  now  brought  down  to  the  side;  the 
acromio-clavicular  joint  is  disarticulated ;  the  conoid  and 
trapezoid  ligaments  are  divided;  the  muscles  of  the  coracoid 
process  are  cut ;  the  capsule  is  incised,  with  the  supraspinatus 
and  infraspinatus,  the  subscapularis  muscles,  and  the  scapular 
origins  of  the  biceps  and  triceps  ;  and  finally  the  teres  major 
and  minor  muscles  are  divided,  the  subscapular  artery  is  tied, 
and  the  bone  is  removed.  The  wound  is  stitched,  a  drain  is 
introduced,  and  antiseptic  dressings  are  applied.  The  patient 
lies  upon  his  back  until  healing  is  well  under  way,  when  the 
arm  is  placed  in  a  sling.  The  drainage-tube  may  be  removed 
in  twent\'-four  hours. 

Excision  of  a  Rib. — In  caries  the  gouge  and  rongeur  may 
remove  the  disease.  In  other  cases  excision  is  performed. 
In  this  operation  the  patient  lies  upon  his  sound  side.  The 
surgeon  faces  the  patient.  Make  an  incision  down  to  the  bone, 
in  the  long  axis  of  the  rib.  The  periosteum,  if  not  diseased,  is 
lifted  from  the  bone,  and  the  intercostal  artery  is  thus  saved 
from  being  cut.  After  sawing  the  bone  beyond  the  limits 
of  disease,  remove  it.  During  the  sawing  a  metal  retractor 
is  held  beneath  the  rib,  between  the  rib  and  the  periosteum. 
If  the  periosteum  is  diseased,  remove  it  after  tying  the  inter- 
costal artery.  Curette  sinuses.  Pack  with  iodoform  gauze 
for  some  days.  Sew  up  the  wound  except  at  one  end. 
Dress  antiseptically  and  apply  a  binder.  If  a  rib  is  re- 
sected in  order  to  drain  the  pleural  cavity,  remove  it  by 
the  subperiosteal  section,  ligate  the  artery  after  one-half 
of  the  rib   has  been   removed,  cut  away  the  periosteum  to 


500 


A   MANUAL    OF  SURGERY. 


prevent   re-formation  of  bone,   and   open  the  pleura.     (See 
Operations  upon  the   Cliest  and  Estlaiiders  Operation.) 

Complete  Excision  of  One-half  of  the  Upper  Jaw. — 
The  whole  upper  jaw  has  been  removed,  but  in  what  fol- 
lows only  resection  of  one-half  the  jaw  will  be  described. 
This  operation  is  performed  for  malignant  tumors  of  the 
superior  maxillary  bone  or  its  antrum.  Up  to  1826,  at  which 
time  Lizars  of  Edinburgh  suggested  the  operation,  tumors 
of  the  antrum  were  treated  by  scraping  them  away  with  a 
sharp  spoon.  Gensoul  of  Lyons  in  1827  performed  the  first 
operation  for  resection  of  the  upper  jaw.  This  operation  is 
not  justifiable,  except  as  a  palliative  measure,  if  the  orbit  is 
invaded,  if  the  skin  and  subcutaneous  tissues  are  infiltrated, 
or  if  the  disease  extends  beyond  the  superior  maxillary  and 
palate  bones.  The  instruments  required  are  a  mouth-gag; 
scalpels ;  strong  scissors ;  dissecting,  toothed,  and  haemo- 
static forceps  ;  bone-cutting  forceps  ;  lion-jawed  and  seques- 
trum forceps;  tooth -extracting 
forceps ;  a  volsella ;  a  narrow- 
bladed  saw ;  a  chisel  and  mallet ; 
a  periosteum-elevator;  a  spatula 
or  metal  retractor;  a  Pacquelin 
cautery;  sponges  which  are  tied 
to  sticks ;  needles,  curved  and 
straight ;  silk  and  catgut  ligatures ; 
silkworm-gut  sutures ;  a  Rever- 
din  needle ;  and  Horsley's  anti- 
septic bone-wax. 

Operation  by  Median  Incision. — 
The  patient,  whose  face  is  shaved, 
is  placed  upon  a  Trendelenburg 
chair,  and  the  head  is  lowered,  thus  avoiding  the  possible 
need  of  instant  tracheotomy.  The  surgeon  stands  upon  the 
right  side  of,  and  faces,  the  patient.     The  incisor  tooth  on 


Fig.  106. — A  B,  Excision  of  the  Upper 
Jaw  ;  c  D  E,  Excision  of  the  Lower  Jaw. 


DISEASES  AND   INJURIES    OF  BONES  AND  JOINTS.      50I 


the  diseased  side  is  pulled  out.  The  incision  (Fig.  106, 
line  ab)  is  begun  half  an  inch  below  the  inner  canthus 
of  the  eye,  and  is  carried  along  the  side  of  the  nose,  around 
the  ala  of  the  nose,  by  the  margin  of  the  nostril,  and  through 
the  middle  of  the  lip.  While  the  lip  is  being  incised  the 
assistant  arrests  hemorrhage  by  grasping  the  corners  of  the 
mouth,  and  after  the  lip  is  divided  the  coronary  arteries  are 
at  once  ligated.  Some  operators  approach  the  mucous 
membrane  cautiously  and  ligate  the  vessels  before  opening 
the  cavity  of  the  mouth.  The  upper  portion  of  the  wound 
having  been  compressed  by  another  assistant  during  these 
manipulations,  pressure  is  now  removed  and  bleeding  points 
are  ligated.  Another  incision  is  now  carried  outward  from 
the  beginning  of  the  first  incision,  along  the  orbital  margin 
to  well  over  the  malar  bone.  The 
flap  is  lifted  from  the  periosteum, 
and  the  bleeding  from  the  infraorbital 
artery  and  the  small  vessels  is  re- 
strained b\'  pressure.  The  nasal  car- 
tilage is  separated  from  the  bone, 
and  the  nasal  process  of  the  superior 
maxillary  is  sawn  (line  a  b.  Fig.  107). 
The  orbital  periosteum  is  lifted  up, 
and  the  orbital  plate  is  cut  with  for- 
ceps from  the  saw-cut  in  the  superior       ^  l    •  •       .  , 

•I  ^  riG.   107. — I.    Jtxcision   of    the 

maxillary  bone  to   the   spheno-max-    Upper  jaw:  a b,  section  of  the 

-'  i  nasal  process;  BC,  section  of  the 

illary  fissure  (line  b  c,  Fig.  107).  The  ^^^'^'bot'lnd^orbua/piate^t 
malar    bone    is    sawn    or    is    bitten    "^^S^rl^ll^^tlh^.S^^ 

■«-U^^,,^'U       „U^ 4-      'i-^      ^^.,< ^       4-1^^       +.       [aw:    G,  section  of  the   inferior 

through      about     its      centre,     the       cut      J^iaxlliary;     h,    section    of    the 
•  •     ,  ,1  1  .         '11  ramus  in  partial  resection. 

running    into    the    spheno-maxillary 

fissure  and  taking  a  downward  and  outward  direction 
(line  c  D,  Fig.  107).  The  soft  parts  covering  the  hard  palate 
are  incised  in  the  median  line,  a  corresponding  incision  is 
made  along  the  floor  of  the  nose  near  the  septum,  and  the 


502  A   MANUAL    OF  SURGERY. 

soft  palate  is  separated  from  the  hard  palate  by  a  trans- 
verse cut.  The  saw  is  introduced  through  the  nose,  and  the 
palate  is  sawn  (line  e,  Fig.  107).  The  upper  jaw-bone  is 
grasped  with  Fergusson's  lion-jaw  forceps  and  removed,  the 
removal  being  aided  by  the  use  of  the  scissors  and  bone- 
cutters  ;  the  latter  are  used  to  separate  the  upper  jaw  and 
the  pterygoid  process  (Treves).  Every  vessel  that  can  be 
seen  is  tied,  and  severe  bleeding  from  bone  is  arrested  by 
antiseptic  wax.  Oozing  is  controlled  by  hot  water  and 
pressure  or  by  the  Pacquelin  cautery.  Examine  carefully 
to  see  if  all  the  diseased  area  is  removed  ;  if  it  is  not,  use 
the  gouge,  scissors,  chisel,  and  saw  until  healthy  tissue  is 
reached.  The  wound  is  packed  with  iodoform  gauze,  and 
the  end  of  the  strip  is  so  placed  as  to  be  accessible  through 
the  mouth.  The  wound  is  sutured  (the  mucous  membrane 
of  the  lip  must  be  stitched,  as  well  as  the  skin)  and  is  dressed 
antiseptically  (the  eye  being  protected  by  aseptic  gauze),  and 
a  crossed  bandage  of  the  angle  of  the  jaw  is  applied. 

Excision  of  One-half  of  the  Lo"wer  Jaw. — In  some  rare 
instances  the  entire  bone  is  removed.  The  lesions  necessi- 
tating removal  of  the  lower  jaw  are  the  same  as  in  the  case 
with  the  upper  jaw.  The  instruments  required  are  those 
used  for  excision  of  the  upper  jaw,  plus  a  metacarpal  saw 
(having  a  movable  back)  and  a  large  curved  needle. 

In  this  operation  the  patient  is  placed  in  the  same  position 
as  that  for  excision  of  the  upper  jaw,  the  chin  being  shaved. 
A  vertical  cut  is  made  through  the  chin-tissue,  starting  below 
the  margin  of  the  lip  and  reaching  to  below  the  border  of 
the  jaw  (c  d,  Fig.  106).  From  the  point  d  an  incision  is  car- 
ried outward  below  the  border  of  the  jaw  and  then  back  of 
the  ramus,  as  shown  in  the  line  d  e  (Fig.  106).  Treves's  ad- 
vice is  to  carry  this  incision  down  to  the  bone,  except  at  the 
line  of  the  facial  artery,  at  which  point  it  must  only  go 
through  the  skin.     The  facial  artery  is  now  to  be  sought 


DISEASES  AND   INJURIES   OF  MUSCLES,   ETC.        503 

for.  tied  in  two  places,  and  divided.  The  periosteum  is  lifted 
from  the  external  surface  of  the  bone,  from  the  symphysis 
outward.  Hemorrhage  is  arrested.  The  buccal  mucous 
membrane  is  cut  from  the  alveolus.  A  lateral  incisor  tooth 
is  pulled,  and  the  bone  is  sawn  in  the  line  g  (Fig.  107). 
The  bone  is  grasped  in  a  lion-jaw  forceps  and  is  drawn  out- 
ward. The  mylo-hyoid  insertion  is  cut;  the  internal  ptery- 
goid muscle  is  cut  or  the  periosteum  at  this  spot  is  lifted  ;  the 
inferior  dental  artery  is  cut  and  tied  ;  the  jaw  is  pulled  down  ; 
the  insertion  of  the  temporal  muscle  upon  the  coronoid  pro- 
cess is  cut  away ;  and  the  external  pterygoid  muscle  is  divided. 
The  capsule  of  the  joint  is  opened,  and  the  bone  is  separated 
from  the  ligaments  which  still  hold  it  in  place.  Bleeding  is 
arrested,  the  wound  is  sutured,  a  tube  is  introduced  in  the 
posterior  portion  of  the  wound  and  retained  for  twenty-four 
hours,  and  antiseptic  dressings  and  a  Gibson  or  a  Barton  band- 
age are  applied.  Partial  excisions  of  the  alveolus  may  be 
performed  through  the  mouth  by  means  of  chisels  and  rongeur 
forceps  ;  but  if  any  considerable  part  of  the  body  of  the  jaw 
is  to  be  removed,  an  incision  should  be  made  below  the  jaw. 


XIX.    DISEASES    AND    INJURIES    OF    MUSCLES, 
TENDONS,  AND    BURS/E. 

Myalgia,  or  muscular  rheumatism,  is  a  painful  disorder 
of  the  voluntary  muscles  and  o^  the  fibrous  and  periosteal 
areas  where  they  are  attached.  The  term  "  muscular  rheu- 
matism "  is  not  strictly  correct.  It  is  possible  that  in  some 
cases  the  muscular  structure  is  inflamed,  but  it  is  certain  that 
in  many  cases  the  pain  is  distinctly  neuralgic.  Muscular 
rheumatism  may  be  due  to  cold  and  wet,  to  over-exertion  and 
strain,  to  acute  infectious  disorders,  to  syphilis,  to  chronic 
intoxications  (lead,  mercury,  and  alcohol),  and  to  disturb- 
ances of  the  circulation.     Gouty  and  rheumatic  persons  are 


504  ^^    MANUAL    OF  SURGERY. 

especially  predisposed,  men  being  more  liable  to  the  disease 
than  women.  The  disease  is  usually  acute,  but  it  may  be 
chronic. 

Symptoms. — Muscular  rheumatism  is  apt  to  come  on  sud- 
denly. The  pain,  which  may  be  very  acute  and  lancinating 
or  may  be  dull  and  aching,  is  in  some  cases  constantly 
present ;  in  other  cases  it  is  awakened  only  by  muscular  con- 
traction. The  pain  is  frequently  relieved  by  pressure,  though 
there  is  often  some  soreness.  The  disease  usually  lasts  for  a 
few  days,  but  it  tends  to  recur.     There  is  little,  if  any,  fever. 

Liimbago  is  myalgia  of  the  muscles  of  the  loins.  Rlien- 
inatic  torticollis  is  myalgia  of  the  muscles  of  the  neck. 
Usually  one  side  of  the  neck  is  attacked.  The  chin  is  turned 
from  the  affected  side  and  the  neck  is  stiff  Pleurodynia 
is  myalgia  of  the  intercostal  muscles.  The  pain  is  very 
severe,  is  aggravated  by  deep  respiration,  by  coughing,  and 
by  yawning,  there  may  be  tenderness,  and  the  patient  tries 
to  limit  chest-movement.  In  intercostal  netiralgia  the  pain 
is  limited,  is  not  constant,  but  occurs  in  distinct  paroxysms, 
and  is  linked  with  the  tender  spots  of  Valleix.  Pleurodynia 
lacks  the  physical  signs  of  pleurisy.  Myalgia  must  not  be 
confused  with  the  pains  of  locomotor  ataxia.  Ccplialodynia 
is  myalgia  of  the  muscles  of  the  scalp.  The  muscles  of  the 
shoulder,  upper  dorsal  region,  abdomen,  and  extremities 
may  also  be  attacked  by  myalgia. 

Treatment. — Remove  any  obvious  cause.  Treat  any  exist- 
ing diathesis,  such  as  gout  or  rheumatism.  Rest  is  of  the 
first  importance.  For  lumbago,  put  the  person  to  bed.  For 
pleurodynia,  strap  the  side  of  the  chest.  A  hypodermatic 
injection  of  morphia  and  atropia  into  the  affected  muscles  at 
once  allays  the  pain,  and  a  deep  injection  of  water  is  often 
curative.  The  introduction  of  four  or  five  aseptic  needles 
into  the  muscles,  and  their  retention  for  a  few  minutes,  often 
acts  like  magic.     Ironing  the  muscles  is  a  good  domestic 


DISEASES  AND   INJURIES   OF  MUSCIES,   ETC.        505 

remedy.  Vigorous  rubbing  of  the  area  with  a  piece  of  ice 
allays  the  pain.  Hot  poultices  do  good.  If  the  pain  is 
widely  diffused,  alters  its  seat,  or  is  very  obstinate,  order 
hot  baths  or  a  Turkish  bath  and  diuretics.  In  chronic  cases 
employ  blisters  or  counter-irritation  by  the  cautery  and  give 
iodide  of  potash  and  nux  vomica.  The  constant  electric 
current  finds  advocates.  In  an  ordinary  severe  case  order 
a  hot  bath,  put  the  patient  to  bed  with  a  hot  poultice  over 
the  part,  and  order  10  grains  of  Dover's  powder;  the  next 
day  give  him  four  times  daily  a  capsule  containing  5  grains 
of  salol  and  3  grains  of  phenacetin. 

Myositis  may  be  a  widespread  inflammation  of  the  volun- 
tary muscles,  due  to  an  unknown  infective  cause.  It  is  a 
disorder  accompanied  by  pain  and  stiffness,  by  cutaneous 
oedema,  and  by  various  parsesthesiae.  Myositis  resembles 
trichinosis,  and  is  distinguished  from  it  only  by  spearing  out 
a  bit  of  muscle  and  examining  it  microscopically.  Occasion- 
ally diffuse  suppuration  occurs.  Ordinary  myositis  arises 
from  injuries,  from  syphilis,  or  from  rheumatism,  and  it  pre- 
sents the  usual  inflammatory  symptoms.  Contraction  and 
adhesion  may  follow. 

Treatment. — Infective  myositis  is  treated  by  anodynes, 
stimulants,  nutritious  food,  hot  applications,  and  rest.  If 
pus  forms,  it  should  be  evacuated.  Rheumatic  myositis  calls 
for  the  salicylates,  the  alkalies,  or  salol.  Syphilitic  myositis 
is  treated  with  mercury  and  iodide  of  potassium.  The  rem- 
edies employed  for  myalgia  are  used  in  traumatic  myositis. 

Hypertrophy  of  the  muscles  may  arise  from  their  in- 
creased use.  In  pseudo -hypertrophic  paralysis  the  bulk  o{ 
the  muscle  is  greatly  augmented,  but  it  contains  less  muscle- 
structure  and  more  fat  or  connective  tissue.  Hypertrophy 
of  the  tongue,  which  is  due  to  lymphangioma,  is  called 
"  macroglossia  "  (see  p.  209). 

Atrophy  of  the  muscles  arises  from  want  of  use,  from 


506  A   MANUAL    OF  SURGERY. 

injury,  from  continuous  pressure,  from  interference  with  the 
blood-supply,  from  disease  of  the  nerves  or  their  centres,  or 
from  lead-poisoning. 

Degeneration  of  Muscles. — The  muscles  may  undergo 
granular  degeneration,  waxy  degeneration,  fatty  degenera- 
tion, and  calcareous  degeneration,  and  may  become  pig- 
mented. 

Local  Ossification  and  Myositis  Ossificans. — It  is  not  un- 
usual for  a  small  portion  of  bone  to  form  in  the  bony  inser- 
tion of  a  muscle  which  is  subjected  to  frequent  strain.  In 
persons  who  ride  many  hours  a  day  there  not  unusually 
develops  the  "  rider's  bone,"  which  is  an  area  of  ossification 
in  the  adductor  muscles  of  the  thigh.  Myositis  ossificans,  a 
widespread  ossification  of  the  muscles,  is  a  rare  disorder  the 
cause  of  which  is  unknown,  and  which,  if  not  congenital, 
begins  at  least  in  early  life. 

Tumors  of  the  Muscles. — Primary  tumors  of  the  muscles 
are  rare.  Among  those  which  may  occur  are  sarcoma, 
fibroma,  lipoma,  osteoma,  angeioma,  myxoma,  and  enchon- 
droma. 

Syphilis  may  cause  inflammation.  Gummata  may  form, 
or  gummatous  infiltration  may  take  place. 

Trichinosis  or  trichiniasis  is  a  disease  due  to  the  embryos 
of  the  trichinae  spiralis.  The  disease  originates  from  eating 
insufficiently  cboked  meat  -which  contains  the  trichinae. 
These  nematodes  are  thus  carried  into  the  intestine,  there 
to  develop  and  to  multiply.  In  from  seven  to  nine  days  a 
horde  of  embryos  have  developed  in  the  intestines,  and  they 
leave  the  intestine  by  passing  through  the  peritoneum  or  by 
means  of  the  blood,  and  finally  reach  the  connective  tissue 
of  the  muscles.  From  the  connective  tissue  the  embryos 
migrate  into  the  primitive  muscle-fibres,  Avhere  they  dwell 
and  enlarge.  Myositis  develops,  and  in  the  course  of  five 
or  six  weeks  the  parasites  become  encapsuled  and  develop 


DISEASES  AND   IXJCK/ES   OF  MCSCLES,    ETC.        507 

no  furtlier.  The  c\'st-wall  may  calcify,  and  the  worm  may 
become  calcified  or  it  may  live  for  years.  Because  infected 
meat  is  eaten  the  disease  does  not  inevitably  develop,  and  a 
few  embryos  lodged  in  muscle  may  cause  no  symptoms. 

Symptoms. — The  symptoms  of  trichinosis  often  appear  in 
a  day  or  two  after  eating  infected  meat.  The  symptoms  of 
acute  gastro-intestinal  catarrh  or  of  cholera  morbus  are  com- 
mon, but  in  some  cases  no  gastro-intestinal  manifestations 
usher  in  the  disease.  In  from  seven  to  fourteen  days  after  the 
infected  meat  is  eaten  the  migration  of  the  parasites  develops 
obvious  symptoms,  A  chill  may  be  noted  ;  there  is  usually 
fever;  muscular  pain,  tenderness,  swelling,  and  stiffness  are 
complained  of  This  condition  may  be  widespread.  Involve- 
ment of  the  muscles  of  mastication  interferes  with  chewing; 
of  the  lar\-nx,  with  audition  and  respiration  ;  of  the  inter- 
costals  and  diaphragm,  with  respiration.  Skin-cedema  and 
itching  are  marked.  In  some  cases  delirium  exists.  The 
writer  saw  in  the  Philadelphia  Hospital  one  fatal  case  which 
was  mistaken  for  erysipelas  because  of  the  high  fever,  the 
delirium,  and  the  oedematous  redness  of  the  face  and  neck. 
Dyspnoea  is  frequent.  Mild  cases  get  w^ell  in  a  week  or  two  ; 
severe  cases  may  last  many  weeks.  The  mortality  varies  in 
different  epidemics  from  i  to  30  per  cent.  (Osier).  The 
diagnosis  is  made  by  spearing  out  a  piece  of  muscle  which 
is  then  examined  for  trichinae  under  a  microscope;  or  the 
worm  may  be  detected  in  the  feces  by  means  of  a  pocket- 
lens. 

Trcatuicnt. — To  treat  trichinosis,  employ  purgatives  (senna 
and  calomel)  early  in  the  case,  and  give  gl\'cerin,  and  also 
santonin  or  filix  mas.  When  muscular  invasion  has  taken 
place,  sedatives,  hypnotics,  nourishing  diet,  and  stimulants 
are  indicated. 

"Wounds  and  Contusions  of  the  Muscles. —  Wounds  of 
muscles  m.ay  be  either  open  or  subcutaneous.    In  a  longitudinal 


5o8  A   MANUAL    OF  SURGERY. 

wound  the  edges  lie  close  together,  and  hence  drainage  must 
be  thorough.  In  a  transverse  wound  the  edges  separate 
widely,  and  catgut  stitches  must  be  inserted.  Contusions  of 
muscles,,  like  contusions  of  other  tissues,  vary  in  extent  and 
in  severity.  There  are  pain  (which  is  increased  by  attempts 
to  use  the  muscle),  loss  of  function,  swelling  beneath  the 
deep  fascia,  and  discoloration,  which  may  appear  at  once 
because  of  superficial  damage  from  the  initial  injury,  or 
which  may  appear  in  dependent  parts  after  many  days  by 
gravitation  of  the  blood  and  the  blood-stained  serum.  As 
a  result  of  contusion,  suppuration,  inflammation,  or  atrophy 
may  arise. 

Treatment. — The  indications  in  wounds  and  contusions  of 
muscles  are  to  obtain  rest  by  means  of  splints  and  to  secure 
relaxation.  Limitation  of  swelling  is  secured  by  bandaging. 
Inflammation  is  combated  first  by  cold  and  lead-water  and 
laudanum,  later  by  iodine,  blue  ointment,  ichthyol,  and  inter- 
mittent heat.  To  prevent  loss  of  function,  employ,  as  soon 
as  the  acute  symptoms  subside,  massage,  passive  motion, 
and  stimulating  liniments,  and,  later  in  the  case,  electricity 
(galvanism  if  the  reactions  of  degeneration  exist,  faradism 
if  they  are  absent). 

Strains  and  Ruptures. — A  strain  is  a  stretching  of  a 
muscle  with  a  small  amount  of  rupture.  The  muscle  is 
swollen,  tender,  stiff,  weak,  and  sore,  and  attempts  at  motion 
produce  sharp  pain.  Strains  are  common  in  the  deltoid,  the 
hamstring  muscles,  the  back,  the  calf,  the  biceps,  and  the 
great  pectoral.  *'  Lawn-tennis  arm  "  is  a  strain  of  the  pro- 
nator radii  teres  muscle.  "  Rider's  leg  "  is  a  strain  of  the 
adductor  muscles  of  the  thigh. 

Treatment. — A  strain  is  treated  in  the  same  way  as  is  a 
contusion. 

Rupture  of  a  muscle  is  announced  by  a  sudden  and  vio- 
lent pain  and  by  loss  of  function  during  powerful  muscular 


DISEASES  AND   INJURIES   OF  MUSCIES,    ETC.        509 

contraction  or  strong  traction  on  a  muscle.  The  rupture 
may  be  announced  by  a  distinctly  audible  snap  (A.  Pearce 
Gould).  A  distinct  gap  is  felt  between  the  ends  ;  great  pain 
develops  on  movement;  there  are  tenderness  and  -swelling. 
Strains  and  ruptures  may  be  followed  by  atrophy,  as  are 
contusions. 

TreaUnciit. — In  treating  rupture  of  an  important  muscle, 
when  the  ends  are  widely  separated,  incise  with  every  aseptic 
care,  unite  the  divided  ends  by  catgut  sutures,  and  sew  up 
the  skin  with  silkworm  gut.  Treat  the  part  in  any  case  by 
rest  and  relaxation,  and  combat  inflammation  by  appropriate 
means.  Passive  motion  and  massage  are  employed  as  soon 
as  union  is  firm. 

Hernia  of  Muscles. — When  a  breach  exists  in  a  muscular 
sheath,  a  portion  of  the  muscle  protrudes.  The  treatment  is 
incision  and  the  stitching  of  the  fascia. 

Contractions  of  muscles  may  result  from  injury,  from 
joint-disease,  from  malposition  of  parts  (as  in  old  disloca- 
tion or  torticollis),  or  from  diseases  of  the  nervous  system. 
The  treatment  in  some  cases  is  sudden  extension,  in  other 
cases  gradual  extension,  tenotomy,  or  myotomy.  Macewen 
recommends  the  making  of  a  number  of  V-shaped  incisions 
in  the  muscle.  In  some  cases  of  spasmodic  contraction 
nerve-stretching  is  of  value. 

Dislocation  of  Tendons. — The  long  head  of  the  biceps 
is  oftenest  displaced.  The  flexor  carpi  ulnaris  and  the  pero- 
neus  brevis  may  be  dislocated.  Most  of  these  accidents  are 
associated  with  chronic  joint  disease  or  with  fracture,  but 
displacement  may  exist  as  a  solitary  injury. 

Symptoms. — In  dislocations  of  the  tendons  the  muscle  will 
contract,  but  it  acts  at  a  disadvantage ;  thus  the  correspond- 
ing joint  exhibits  partial  loss  of  function.  The  displaced 
tendon  can  be  felt,  and  a  hollow  exists  where  it  used  to 
reside. 


5IO  A   MANUAL    OF  SURGERY. 

Treatment. — In  tendon-dislocation  reduction  is  easy,  but 
the  displacement  is  apt  to  recur  because  of  laceration  of  the 
sheath.  The  treatment  is  by  splints  and  by  lead-water  and 
laudanum.  Passive  movements  arc  begun  at  the  end  of  the 
first  week.  Even  if  the  tendon  will  not  stay  reduced,  a  use- 
ful joint  will  be  obtained.  Wood  of  New  York  advised  in 
obstinate  cases  tenotomy  and  immobilization.  Open  incision 
may  be  necessary. 

Wounds  of  Tendons. — Subcutaneous  wounds  of  tendons 
are  usually  inflicted  by  the  surgeon,  and  they  heal  well. 
Open  wounds  require  rigid  antisepsis  and  the  suturing  of 
the  tendon.  In  wounds  of  the  wrist  especially  always  suture 
the  tendons  (Figs.  109  to  112),  and  be  sure  to  bring  the 
proper  ends  into  apposition. 

Rupture  of  Tendons. — A  violent  muscular  effort  may 
rupture  a  tendon,  and  a  snap  can  often  be  heard.  The  symp- 
toms are  sudden  pain  and  loss  of  power,  fulness  of  the  asso- 
ciated muscle  from  retraction,  and  absolute  inability  to  bring 
the  tendon  into  action.  A  gap  can  often  be  felt  in  the 
tendon. 

Treatment. — The  best  procedure  in  treating  rupture  of  a 
tendon  is  incision  and  tendon-suture.  Some  surgeons  relax 
the  parts  and  apply  splints. 

Thecitis  or  teno-synovitis  is  inflammation  of  the  sheath 
of  a  tendon. 

Acute  thecitis  may  arise  from  a  contusion,  from  a  wound, 
from  repeated  over-action  in  working,  from  rheumatism,  from 
gonorrhoea,  or  from  syphilis. 

Symptoms. — In  n on- suppurative  cases  of  thecitis  the  symp- 
toms are  pain,  swelling,  tenderness,  and  moist  crepitus  along 
the  tendon-sheath,  due  to  inflammatory  roughening.  The 
crepitus  disappears  as  the  swelling  increases,  but  it  reappears 
as  the  swelling  diminishes.  In  suppurative  cases  the  symp- 
toms are  great  swelling,  pulsatile  pain,  dusky  discoloration, 


DISEASES  AND   INJURIES    OF  MUSCLES,   E  TC.        5  I  I 

inflammation  spreading  up  the  tendon-sheaths,  and  the  con- 
stitutional symptoms  of  sepsis. 

Treatment. — In  treating  non-suppurative  thecitis,  employ 
splints  and  apply  locally  iodine,  blue  ointment,  or  ichthyol. 
Treat  any  causative  constitutional  state.  In  the  suppurative 
form  make  free  incisions,  irrigate,  and  drain. 

Palmar  Abscess. — A  suppurative  thecitis  of  the  flexor 
tendons  of  the  fingers  travels  rapidly  upward  and  is  apt  to 
produce  a  palmar  abscess.  Thecitis  of  one  of  the  three 
middle  fingers  is  usually  arrested  at  the  lower  end  of  the 
palm,  but  suppurative  thecitis  of  the  thumb  or  the  little 
finger  diffuses  pus  over  a  large  surface  of  the  palm  and  also 
up  the  arm.  Palmar  abscess  is  a  most  serious  affection. 
The  pus  may  dissect  up  all  the  structures  of  the  palm, 
may  reach  the  dorsum,  or  may  pass  beneath  the  anterior 
annular  ligament  into  the  connective-tissue  planes  of  the 
forearm. 

Treatment. — A  palmar  abscess  demands  free  incision  and 
drainage  at  the  earliest  possible  moment.  The  incision  is 
made  in  the  line  of  the  metacarpal  bone.  A  line  transverse 
with  the  web  of  the  thumb  is  below  the  palmar  arches.  In 
an  incision  above  this  line,  try  not  to  cut  the  arch,  but  if  it 
be  cut,  ligate  at  once. 

Chronic  thecitis  is  usually  a  tubercular  inflammation  of 
a  tendon-sheath.  The  swelling  is  firm  or  doughy  when  due 
to  granulation  tissue,  but  is  fluctuating  when  due  to  fluid. 
Grating  is  marked.  The  tendon-sheath  may  contain  numer- 
ous small  bodies  which  are  either  free  or  are  attached  (rice, 
riziform,  or  melon-seed  bodies).  Tubercle  bacilli  are  present 
in  the  fluid  or  in  the  granulation  tissue.  Chronic  thecitis  is 
commonest  in  the  tendons  of  the  fingers,  the  ankle,  and  the 
knee ;  it  may  spread  to  a  joint  or  it  may  arise  from  a  tuber- 
cular joint.  ^  This  condition  causes  very  little  pain. 

Treatment. — In   cases  of  fluid  efl"usion,  make  a  small  in- 


512  A   MANUAL    OF  SURGERY. 

cision,  wash  out  with  iodoform  emulsion,  and  close  the 
wound.  In  cases  of  rice  bodies,  open  the  sheath,  evacuate 
the  contents,  scrape  the  walls  thoroughly,  inject  with  iodo- 
form emulsion,  and  close  the  wound.  (If  the  annular  liga- 
ment is  divided,  stitch  it  together;  Fig.  112.)  In  cases  with 
extensive  formation  of  embryonic  tissue,  apply  an  Esmarch 
bandage,  make  a  large  incision,  and  remove  all  infected  tis- 
sue from  the  sheath,  around  the  sheath,  and  from  the  tendon. 

Gang-lia. — In  connection  with  tendon-sheaths  simple 
ganglia  may  develop.  They  are  small,  tense,  round  swell- 
ings, which  are  firm,  grow  progressively  though  slowly, 
are  painless  when  uninflamed,  and  contain  a  fluid  of  the 
appearance  and  consistence  of  glycerin  jelly  (Bowlby). 
These  ganglia  are  commonest  upon  the  dorsum  of  the  wrist, 
and  they  occur  especially  in  those  who  constantly  use  the 
wrist-muscles.  Paget  states  that  a  simple  ganglion  is  due 
to  cystic  degeneration  of  a  synovial  fringe  inside  a  tendon- 
sheath,  and  that  the  fluid  of  the  ganglion  does  not  communi- 
cate with  the  fluid  of  the  tendon-sheath.  Other  pathologists 
believe  a  simple  ganglion  to  be  a  hernia  of  synovial  mem- 
brane through  a  rent  in  a  tendon-sheath,  all  way  of  com- 
munication being  soon  obliterated.  Compoimd  ganglion  is 
an  old  name  for  tubercular  thecitis. 

Treatment. — Ganglia  are  treated  by  aseptic  puncture  with 
a  tenotome,  evacuation,  scarification  of  the  walls,  antisep- 
tic dressing,  and  pressure.  An  old-time  method  of  treat- 
ment was  subcutaneous  rupture  brought  about  by  striking 
with  a  heavy  book.  Recurrent  ganglia,  very  large  ganglia, 
and  ganglia  with  very  thick  contents  should  be  dissected 
out. 

Felon,  "whitlo"w,  or  paronychia  is  a  suppuration  of  a 
finger  or  a  toe  due  to  abrasion  which  may  be  very  slight, 
pus  organisms  being  carried  inward.  The  commonest  seat 
oi  a  felon  is  the  last  digit  of  a  finger,  because  the  superficial 


DISEASES  AND   INJURIES   OF  MUSCLES,   ETC.        513 

lymphatics  run  directly  inward.  Superficial  felon  usually 
occurs  in  children  and  in  persons  broken  down  in  health. 
More  than  one  finger  is  apt  to  be  attacked,  and  the  felon 
usually  appears  as  a  suppuration  around  the  nail  (a  ring- 
around).  The  symptoms  are  pain,  suppuration,  and,  in  bad 
cases,  loss  of  the  nail.  In  deep  felon  (bone-felon)  the  finger 
is  very  hot,  tense,  and  painful,  the  pain  being  pulsatile  and 
much  increased  by  motion,  by  pressure,  or  by  a  dependent 
position.  Pus  soon  forms.  An  abscess  may  form  in  the 
superficial  tissues  as  well  as  in  the  depths. 

Treatment. — A  superficial  felon  demands  instant  incision 
in  all  cases,  and  the  patient  should  subsequently  be  ordered 
tonics  and  a  change  of  air.  A  bone-felon  should  be  incised 
at  once  to  the  bone  alongside  the  tendon.  Do  not  wait 
for  pus  to  form,  but  allay  tension  and  prevent  pus-formation 
by  early  incision.  Do  not  waste  time  v/ith  poultices :  to 
wait  means  agonizing  pain,  sleepless  nights,  constitutional 
involvement,  and  perhaps  sloughing  of  tendons  or  death 
of  the  bone.  Incision  and  drainage  constitute  tlie  treatment, 
followed  by  irrigation,  antiseptic  dressing,  and  splinting  of 
the  extremity.  If  the  patient  cannot  sleep,  give  morphia. 
See  that  the  bowels  are  moved  once  a  day.  Give  quinine, 
iron,  and  milk  punch.  Opening  a  felon  is  exquisitely  pain- 
ful ;  hence  ether  should  be  given  to  the  first  stage,  nitrous 
oxide  should  be  administered',  or  the  superficial  parts  should 
be  frozen  by  a  spray  of  chloride  of  ethyl. 

Bursitis  is  the  inflammation  of  a  bursa.  Acute  bursitis 
arises  from  strain  or  from  traumatism.  The  symptoms  of 
acute  bursitis  are  pain,  limited  swelling,  moist  crepitus,  fluc- 
tuation, and  discoloration  in  the  anatomical  position  of  a 
bursa.  Bursitis  of  a  deep  bursa  is  hard  to  separate  from 
synovitis  ;  indeed,  the  joint  is  apt  to  become  secondarily 
affected.  Suppuration  may  take  place.  Chronic  bursitis 
may  follow  acute  bursitis,  or  the  disease  may  be  chronic  from 
33 


514  A   MANUAL    OF  SURGERY. 

the  start.     Its  symptom  is    swelling  with  little  or  no  pain 
unless  acute  inflammation  arises. 

Treatment. — Acute  bursitis  is  treated  at  first  by  rest  and 
pressure  and  with  lead-water  and  laudanum ;  later  with 
iodine,  blue  ointment,  or  ichthyol.  If  the  swelling  persists, 
aspirate.  If  pus  forms,  incise,  swab  out  the  sac  with  pure 
carbolic  acid,  and  pack  it  with  iodoform  gauze.  If  some 
causative  diathesis  exists,  it  should  be  treated. 

Housemaid's  knee  is  thickening  and  enlargement  of  the 
prepatellar  bursa  due  to  intermittent  pressure.  In  effusion 
into  the  knee-joint  the  fluid  is  behind  the  patella  and  the 
bone  floats  up ;  in  housemaid's  knee  the  fluid  is  above 
the  bone  and  the  osseous  surface  can  be  felt  beneath  it. 
**  Miner's  elbow,"  which  is  a  condition  similar  to  housemaid's 
knee,  affects  the  olecranon  bursa. 

Treatment. — Housemaid's  knee  is  treated  by  incision  and 
packing  with  iodoform  gauze.  In  bursitis  of  the  bursa  be- 
neath the  ligamentum  patellae,  if  rest  and  blistering  fail  to 
cure,  aspirate  or  incise.  In  bursitis  below  the  tendon  of  the 
semimembranosus,  incise  or  aspirate. 

Bunion. — A  bunion  is  a  bursa  due  to  pressure,  and  it  is 
most  commonly  found  above  the  metatarso-phalangeal  articu- 
lation of  the  great  toe,  but  occasionally  over  the  joint  of 
another  toe.  When  the  big  toe  is  pushed  inward  by  ill- 
fitting  boots  a  bunion  forms.  When  a  bunion  is  not  in- 
flamed it  may  cause  but  little  trouble,  but  when  it  is  inflamed 
the  bursa  enlarges  and  the  parts  become  hot,  tender,  and 
excessively  painful.  Suppuration  may  occur  and  pus  may 
invade  the  joint,  and  the  bone  not  unusually  becomes  dis- 
eased. 

Treatment. — In  treating  a  bunion  the  patient  must  wear 
shoes  that  are  not  pointed,  that  have  the  inner  borders 
straight,  and  that  have  rounded  toes  (Jacobson).  For  a 
mild  case  a  bunion-plaster  gives  comfort.     Dr.  Sayre  advises 


DISEASES  AND   INJURIES   OF  AIUSCIES,   ETC.        515 

the  use  of  a  linen  glove  over  the  phalanges,  which  are  to  be 
drawn  inward  by  a  piece  of  elastic  webbing  one  end  of  which 
is  fastened  to  the  glove  and  the  other  end  to  a  piece  of  strap- 
ping from  the  heel.  A  special  apparatus  may  be  worn  (Fig, 
108).  In  many  cases  osteotomy  of  the  first  phalanx  or  of  the 
first  metatarsal  bone  is  required ;  in  some  cases  excision  of 
the  joint  is  necessary ;  in  others  amputation 
must  be  performed.  When  the  bursa  is  not 
inflamed,  but  only  thickened,  blisters  should 
be  employed  over  it,  or  there  should  be  ap- 
plied tincture  of  iodine,  ichthyol,  or  mercurial 
ointment.  When  the  bursa  inflames,  lead- 
water  and  laudanum  is  applied,  and  intermit- 
tent heat  by  foot-baths  gives  relief.    Suppura- 

1  J      •  J-    ..      •        •    •  A         .■  .-  Fig.    108.— Bigg's 

tion  demands  mimediate  mcision  and  antiseptic  Apparatus  for  Bun- 
dressing.    If  an  ulcerated  bunion  does  not  heal 
by  antiseptic  dressing,  stimulate  it  with  silver  and  dress  it 
with   unguent,  hydrarg.  nitrat.  (i   part  to  7  of  cosmoline). 
Jacobson  recommends  skin-grafting  for  some  cases. 

Operations  upon  Tendons. — Tenotomy  is  the  cutting  of 
a  tendon.  It  may  be  open  or  subcutaneous,  the  open  opera- 
tion being  preferred  in  dangerous  regions,  and  the  method 
of  its  performance  being  obvious.  The  subcutaneous  method 
will  here  be  described. 

Tenotomy  of  the  Tendo  Achillis. — In  this  operation  the 
tendon  is  cut  about  one  inch  above  its  point  of  insertion. 
The  instrument  used  is  a  sharp  tenotome.  The  patient  lies 
upon  his  back  '*  with  his  body  rolled  a  little  toward  the 
affected  side  "  (Treves),  the  foot  being  placed  upon  its  outer 
side  on  a  sand  pillow.  The  surgeon  stands  to  the  outside. 
The  tendon  is  rendered  moderately  rigid,  and  the  sharp 
tenotome,  with  its  blade  upward,  is  carried  inward  along 
the  anterior  border  of  the  tendon  until  the  surgeon's  finger 
feels  the  knife  on  the  outer  side.     The  tendon  is  now  drawn 


5i6 


A   MANUAL    OF  SURGERY. 


into  rigidity,  and  the  surgeon  turns  the  blade  of  his  knife 
toward  the  tendon,  places  his  finger  over  the  skin,  and 
saws  toward  his  finger.  The  tendon  gives  way  with  a  snap. 
Treves  states  that  a  beginner  is  apt  not  to  push  his  knife  far 
enough  toward  the  outside  or  he  may  push  his  knife  through 
the  tendon ;  in  either  case  the  tendon  is  not  completely  cut. 
The  little  wound,  which  is  covered  with  a  bit  of  gauze,  will 
be  entirely  closed  in  forty-eight  hours.  In  club-foot  cases 
after  tenotomy  some  surgeons  at  once  correct  the  deformity 
and  immobilize  the  limb  in  plaster ;  some  partially  correct 
the  deformity  and  apply  plaster  for  one  week,  at  which  time 
they  remove  the  plaster,  partly  correct  the  deformity,  reapply 
the  plaster,  and  so  on ;  other  surgeons  do  not  attempt  cor- 
rection of  the  deformity  until  the  cut  tendon  has  begun  to 
unite,  when  they  gradually  stretch  the  new  material. 

Tendon-suture    and  Tendon-leng-thening-. — The    instru- 
ments required  in  these  operations  are  an  Esmarch  apparatus ; 

L 


1 


Fig.  109.— Tendon-sutures  :  A,  of  Le  Fort; 
B,  of  Le  Dentu;  c,  of  Lejars. 


Fig.   no.— Anderson's  Method  of  Ten- 
don-lengthening. 


curved  needles  and  needle-holder;  chromicized  gut,  kangaroo 
tendon,  or  silk  for  an  ordinary  case,  silver  wire  for  a  sup- 
purating wound.  In  performing  tendon-suture,  make  the  part 
aseptic  and  bloodless  ;  find  the  ends  of  the  tendon,  and  be 
sure  the  proper  ends  are  brought  into  contact ;  stitch  them 
together  with  a  continuous  suture  or  with  one  of  the  sutures 
shown  in  Figure   109,  a,  b,  and  c.     In  a  suppurating  wound 


ORTHOPEDIC  SURGERY.  517 

suture  by  silver  wire  should  be  tried,  though  it  usually  fails. 
After  suturing,  remove  the  Esmarch  apparatus,  arrest  bleed- 
ing, suture  the  wound  and  dress  it  antiseptically,  relax  the 
parts,  and  place  the  limb  on  a  splint.  If  a  flexor  tendon  of 
the  wrist  is  cut,  approximate  the  ends  by  flexing  the  finger 
of  the  cut  tendon  and  extending  the  other  fingers.  If,  after 
suturing,  there  is  much  tension,  stitch  the  cut  tendon  above 
the  sutures  to  an  adjacent  tendon.  Dress  with  plaster,  the 
finger  of  the  cut  tendon  being  flexed,  the  others  being  ex- 
tended. Begin  passive  motion  after  one  week.  If  only  one 
end  of  the  tendon  can  be  found,  graft  it  upon  the  nearest 
tendon  with  a  like  anatomical  course  and  function.  In  old 
injuries,  when  the  ends  cannot  be 
brought  into  apposition,  lengthen 
one  end  or  both  ends  either  by  the 
method  of  Czerny  (Fig.  iii)  or  by 
the  method  of  Anderson  (Fig.  1 10). 

/       ^  Fig.  112. — Method  of  Suturing 

the    Annular    Ligament    of   the 
Fig.  III. — Czerny's  Method  of  Tendon-lengthening.         Wrist. 

These  methods  of  lengthening  may  be  used  in  cases  of  de- 
formity from  a  contracted  tendon.  If  the  tendon  cannot  be 
lengthened  sufficiently,  make  a  bridge  of  catc^ut  from  one 
end  of  it  to  the  other,  or  graft  in  another  tendon  from  the 
same  person  or  from  one  of  the  lower  animals. 

The  annular  ligament  is  sutured  as  shown  in  Figure  112. 

XX.   ORTHOPEDIC  SURGERY. 

This  branch  of  surgery  formerly  dealt  only  with  the  treat- 
ment of  deformities  by  means  of  mechanical  appliances,  but 
of  recent  years  its  domain  has  been  enlarged  to  include  the 
treatment,  surgical  and  mechanical,  of  deformities,  contrac- 
tures, and  many  joint   diseases. 


5l8  A   MANUAL    OF  SURGERY. 

Torticollis  (wry-neck)  is  a  condition  in  which  contraction 
of  certain  of  the  neck-muscles  causes  an  alteration  in  the 
position  of  the  head.  The  disease  is  one-sided  ;  the  sterno- 
cleido-mastoid  is  the  muscle  chiefly  involved,  though  the 
trapezius,  splenius,  and  other  muscles  sometimes  suffer. 
Acute  torticollis,  which  is  rare,  results  from  cold  or  from 
injury  (see  Myalgia).  Chronic  torticollis  may  be  congenital, 
it  may  be  due  to  nerve-irritation,  or  it  may  be  due  to  an 
assumed  attitude  because  of  eye-defect.  Chronic  torticollis 
may  be  intermittent,  but  is  usually  spastic.  The  muscle 
stands -out  in  bold  outline,  the  head  is  turned  to  the  oppo- 
site side,  the  ear  of  the  disordered  side  is  turned  toward  the 
shoulder,  and  the  chin  is  thrown  forward.  There  is  no  pain. 
Spinal  curvature  may  arise.  The  head  can  often  be  restored 
to  its  normal  position  by  passive  movement  or  by  voluntary 
effort,  but  it  at  once  returns  to  its  habitual  position.  The 
corresponding  side  of  the  face  atrophies. 

Symptovis. — Congenital  wry-neck  is  due  to  central  nervous 
disease,  to  spinal  deformity,  or  to  injury  during  delivery,  and 
in  this  form  the  sterno-mastoid  is  shortened,  hardened,  and 
atrophied.  It  may  not  be  noticed  for  some  years  because  of 
the  short  neck  of  infancy,  and  it  is  associated  with  asymmet- 
rical development  of  the  face.  It  is  almost  invariably  upon 
the  right  side.  Spasmodic  wry-neck  may  present  tonic  spasm 
only,  intermittent  spasm  alone,  or  both  may  appear  alter- 
nately. It  is  a  disease  especially  of  adults  ;  in  women  it  is 
often  linked  with  hysteria.  The  exciting  cause  may  be  a 
cold,  a  blow,  or  a  mental  storm  ;  the  predisposing  cause  is 
the  neurotic  temperament.  In  some  rare  cases  bilateral 
spasm  occurs,  the  head  being  pulled  backward  and  the  face 
being  turned  upward.  Clonic  spasms  may  come  on  unan- 
nounced, or  they  may  be  preceded  by  pain  and  stiffness ; 
the  head  can  be  held  still  for  a  moment  only ;  there  is 
sometimes  pain,  always  fatigue,  but  during  sleep  the  contrac- 


ORTHOPEDIC  SURGERY.  5  I9 

tions  cease.  The  attack  will  probably  pass  away,  but  will 
almost  certainly  recur. 

Treatment. — Congenital  wry-neck  is  treated  by  tenotomy 
(through  an  open  wound)  and  the  use  of  proper  braces 
and  supports.  The  old  subcutaneous  tenotomy  should 
be  abandoned,  as  aseptic  incision  enables  the  surgeon  to 
see  and  to  feel  all  the  contracted  bands  of  fascia,  muscle, 
and  tendon,  and  to  avoid  dangerous  structures.  In  spas- 
modic wry-neck  treat  the  neurotic  temperament ;  in  per- 
sistent cases  stretch,  or  divide  and  exsect  a  part  of  the 
spinal  accessory  nerve.  To  reach  this  nerve,  make  an  in- 
cision along  the  posterior  edge  of  the  sterno-cleido-mastoid, 
find  the  nerve  as  it  emerges  from  under  the  middle  of  the 
muscle,  and  retract  the  muscle  at  this  point.  For  the  treat- 
ment of  rheumatic  wry-neck  see  Myalgia  (p.  504). 

Dupuytren's  contraction  is  a  contraction  of  the  palmar 
fascia,  of  its  digital  prolongations,  and  of  the  fibres  joining 
the  fascia  and  skin.  Fixed  contraction  of  one  or  of  more 
fingers  occurs.  The  ring-finger  and  the  little  finger  most 
often  suffer.  The  disease  arises  oftenest  in  men  beyond 
middle  age.  The  cause  of  this  disease  is  unknown :  some 
think  it  is  gout  or  rheumatism,  others  that  it  is  trauma- 
tism, reflex  irritation,  or  neuritis. 

Symptoms. — Dupuytren's  contraction  is  indicated  by  a 
small  hard  lump  or  crease  which  appears  over  the  palmar 
surface  of  the  metacarpo-phalangeal  joint.  This  nodule 
grows  and  the  corresponding  finger  is  pulled  down.  In 
some  cases  the  tip  of  the  finger  is  forced  against  the  palm. 
The  skin  becomes   dimpled  or  puckered. 

Treatment. — In  treating  Dupuytren's  contraction  subcu- 
taneous multiple  incisions  may  be  made,  the  tense  fascia  and 
the  fascio-cutaneous  fibres  being  cut.  The  finger  is  straight- 
ened and  is  placed  upon  a  straight  splint,  which  is  worn 
continuously  for  a  week  or  ten  days  and  is  worn  at  night 


520 


A   MANUAL    OF  SURGERY. 


for  at  least  a  month.  Dr.  Keen  divides  the  skin  by  a 
V-shaped  cut,  the  base  of  the  V  being  down,  and  dissects 
out  the  contracted  tissue. 

Syndactylism  (webbed  fing-ers)  is  always  congenital,  and 
may  persist  through  several  generations.  Simple  incision 
of  the  web  is  useless ;  the  operation  to  be  performed  is  that 
of  Agnew  or  of  Diday  (Figs.  113,  114). 


Fig.  113. — Agnew's  Operation  for  Webbed 
Fingers  (Pye). 


Fig.   114. — Diday's   Operation   for 
Webbed  Fingers  (Pye). 


Polydactylism  (supernumerary  digits)  is  always  con- 
genital, is  often  hereditary,  and  is  usually  symmetrical. 
There  may  be  an  incomplete  digit,  or  there  may  be  an  entire 
and  well-developed  finger  or  toe  with  a  metacarpal  or  meta- 
tarsal bone.  The  connection  to  the  metatarsus  or  metacar- 
pus may  be  by  a  fibrous  pedicle  only.  If  the  digit  is  com- 
plete, with  a  metacarpal  bone,  no  operation  is  required ;  if  it 
is  incomplete  or  is  ill-developed,  it  should  be  removed. 

Genu  valg-um  (knock-knee)  results  from  an  unnatural 
growth  of  the  internal  condyle,  causing  the  shaft  of  the 
femur  to  curve  inward  and  the  internal  lateral  ligament  of 
the  knee-joint  to  stretch,  the  knees  coming  close  together 
and  the  feet  being  widely  separated.  This  deformity  is  usu- 
ally noted  when  the  child  begins  to  walk,  but  it  may  not 
appear  until  puberty  or  even  long  after.  Knock-knee  may 
arise  from  rickets,  from  an  occupation  demanding  prolonged 
standing,  or  from  flat-foot.  It  may  be  noted  in  one  knee  or 
in  both  knees. 


ORTHOPEDIC  SURGERY 


521 


Treatment. — Mild  rhachitic  cases  of  knock-knee  may  re- 
main in  slight  deformity  or  may  get  well  from  improvement 
of  the  general  health.  In  ordinary  cases,  simply  treat  the 
rickety  condition.  The  patient  is  forbidden  to  stand  or  to 
walk,  and  the  limb,  after  being  put  as  straight  as  it  can  be, 
is  fixed  on  an  external  splint  and  a  pad  is  put  over  the 
inner  condyle.  Later  in  the  case  plaster-of-Paris  is  used. 
Some  surgeons  prefer  to  immobilize,  in  which  case  the  leg 
is  flexed  to  a  right  angle  with  the  thigh.  In  a  severe  case 
the  surgeon  can  immobilize  after  forcibly  straightening 
(causing  an  epiphyseal  separation)  or  after  the  performance 
of  osteotomy  (Fig.  90).  Osteotomy  is  preferable  to  fracture 
by  a  mechanical  appliance  (osteoclasis). 

Genu  varum  (bow-legs)  is  the  opposite  of  knock-knee. 
Usually  both  legs  are  bowed  out,  the  knees  being  widely 
separated,  the  tibiae  and  femurs,  as  a  rule,  being  curved,  and 
the  feet  being  turned  in.  This  disease  is  due  to  rickets,  the 
weight  of  the  body  producing  the  deformity  in  early  life. 
In  older  people  incurable 
bow-legs  may  arise  from  ar- 
thritis deformans. 

Treatment.  —  Some  mild 
cases  of  genu  varum  recover 
from  improvement  of  the 
health.  Ordinary  cases  are 
treated  by  braces,  by  plaster- 
of-Paris  bandages,  and  by 
attention  to  the  general 
health.  When  the  bones 
have  hardened,    osteotomy    or    osteoclasis    is   indicated. 

Talipes  (club-foot)  is  a  deviation  of  the  foot  not  due  to 
traumatism.  Talipes  equiniis  (Fig.  115)  is  a  confirmed  ex- 
tension; tcdipes  calcaneus  (Fig.  1 16)  is  a  confirmed  flexion; 
talipes  varus  is  a  confirmed  adduction  ;  and  talipes  valgus  is 


Fig.  115. — Talipes 
Equinus  (Albert). 


Fig.  116. — 'Jalipes 
Calcaneus  (Albert). 


522 


A   MANUAL    OF  SURGERY. 


Fig.  117. — Double    Equino-varus    {Am.  Text-book 
of  Surgery). 


a  confirmed  abduction.  Two  of  these  forms  may  be  com- 
bined, as  in  equino-varus  (Fig.  1 17).  The  causes  of  tahpes  are 
undcr-action  of  some  muscles,  over-action  of  other  muscles, 
or  abnormahty  of  bony  form  or  position  ;  it  may  be  congeni- 
tal or  it  may  be  ac- 
quired. The  acquired 
form  arises  from  infan- 
tile paralysis ;  the  con- 
genital form  is  due  to 
persistence  of  the  foetal 
form  of  the  foot. 

Symptoms  and  Treat- 
ment.— In  club-foot  the 
position  is  obvious.  In 
congenital  cases  the  condition  is  usually  manifest  on  both 
sides,  and  is  nearly  always  talipes  equino-varus.  Congenital 
club-foot,  where  a  restoration  to  position  can  take  place, 
is  treated  by  plaster-of-Paris  bandages.  If  a  child  has 
begun  to  walk,  it  may  still  be  possible  to  correct  the  deform- 
ity eventually  by  manipulations,  by  plaster-of-Paris  bandages, 
or  by  club-foot  shoes,  but  most  cases  require  tenotomy 
of  the  tendo  Achillis  before  the  application  of  the  shoe  or 
the  plaster.  The  club-foot  shoe  may  do  good  service,  but  in 
many  instances  it  is  painful  and  is  not  so  efficient  as  plaster. 
In  severe  cases,  before  applying  the  plaster,  the  patient  is 
given  ether ;  the  surgeon  cuts  the  tendo  Achillis,  the  ten- 
dons of  the  anterior  and  posterior  tibial  muscles,  and  the 
plantar  fascia,  and  forcibly  corrects  the  deformity.  In  old 
cases  with  alteration  in  the  shape  of  the  bones,  cuneiform 
osteotomy  (p.  474),  or  the  removal  of  the  cuboid  or  other 
tarsal  bones,  is  indicated.  In  these  cases  Phelps  advises  a 
transverse  incision  through  all  the  plantar  soft  parts.  In 
talipes  due  to  infantile  paralysis  the  operative  treatment  is 
the  same.     Do  not  immobilize  in  plaster,  but  rather  in  some 


ORTHOPEDIC  SURGERY. 


52: 


Fig.  118. — Print  of  a 
Normal  Foot-sole  (a) 
and  of  a  Flat  Foot-sole 
(b)  (Albert). 


apparatus  which  can  easily  be  removed  to  permit  the  use  of 
massage  and  electricity.  In  some  cases  of  talipes  calcaneus 
the  surgeon  may  be  forced  to  shorten  the  tendo  Achillis. 

Pes  planus  (flat-foot)  is  the  loss  of  the  arch  of  the  foot, 
due  to   ligamentous   weakness   and  to  prolonged   standing. 
This    condition    is    productive    of  much  pain  on  standing. 
Flat-foot   can    at    once    be    recognized    by 
wetting  the  sole  of  the  patient's  foot  with 
a  colored    fluid   and   causing  him  to  step 
firmly  upon  a  piece  of  paper  (Fig.  1 18,  A,  b). 

Treatment. — To  treat  flat-foot  deformity 
a  shoe  should  be  made  containing  a  piece 
of  steel  so  arranged  as  to  raise  the  arch 
of  the  foot.  The  patient's  general  health 
must  also  be    looked  to. 

Pes  cavus  (hollow-foot)  is  an  increase 
in  the  arch  of  the  foot,  due  to  contraction 
of  the  peroneus  longus  muscle  or  to  paralysis  of  the  muscles 
of  the  calf     It  is  the  opposite  of  flat-foot. 

Treatment. — A  shoe  is  worn  containing  a  plate  of  steel  in 
the  sole,  and  pressure  is  applied  over  the  instep.  Tenotomy, 
cutting  of  the  plantar  fascia,  or  excision  of  bone  may  be 
required. 

Hallux  valgus  or  varus,  a  displacement  of  the  great  toe 
outward  or  inward,  may  occur  in  the  young,  but  it  is  most 
frequent  in  old  men ;  it  may  be  due  to  rheu- 
matic gout.  In  hallux  valgus  a  bunion  is  apt 
to  form. 

Treatment. — An  arrangement  may  be  worn 
to  straighten  the  toe  and  to  protect  the  bun- 
ion, osteotomy  may  be  performed  upon  the  metatarsal  bone, 
the  joint  may  be  excised,  or  amputation  may  be  required. 

Hamraer-toe  (Fig.  119)  is  the  flexion  of  one  or  more  toes 
at  the  first  interphalangeal  joint.     Shattuck  shows  that  this 


Fig.  119. — Ham- 
mer-toe. 


524  A   MANUAL    OF  SURGERY. 

condition  is  due  to  contraction  of  "  the  plantar  fibres  of  the 
lateral  ligaments  of  the  joint."  ^  This  disease  usually  begins 
in  youth.  A  bunion  is  apt  to  form,  and  the  joint  may  be 
dislocated.  The  treatment  is  excision  of  the  joint  or  ampu- 
tation. 


XXI.  DISEASES  AND  INJURIES  OF  NERVES. 

I.  Diseases  of  Nerves. 

Neuritis,  or  inflammation  of  a  nerve,  may  be  limited 
or  be  widely  distributed  (multiple  neuritis).  The  first-men- 
tioned form  will  here  be  considered.  The  causes  of  neuritis 
are  traumatism,  wounds,  over-action  of  muscles,  gout,  rheu- 
matism, syphilis,  fevers,  and  alcohol. 

Symptoms. — The  symptoms  of  neuritis  are  as  follows : 
Excessive  pain,  usually  intermittent,  in  the  area  of  nerve- 
distribution.  The  pain  is  worse  at  night,  is  aggravated  by 
motion  and  pressure,  and  occasionally  diffuses  to  adjacent 
nerve-areas  or  awakens  sympathetic  pains  in  the  opposite 
side  of  the  body.  The  nerve  is  very  tender.  The  area  of 
nerve-distribution  feels  numb  and  is  often  swollen.  Early 
in  the  case  the  skin  is  hyperaesthetic  ;  later  it  may  become 
anaesthetic.  The  muscles  atrophy  and  present  the  reactions 
of  degeneration ;  that  is,  the  muscles  first  ceases  to  respond 
to  rapietfy-interruptQd,  and  next  to  s/owfy-'mterruptcd,  faradic 
currents  ;  faradic  excitability  diminishes,  but  galvanic  excita- 
bility increases.  When,  in  neuritis,  faradism  produces  no 
contraction,  a  slowly-interrupted  galvanic  current  which  is 
so  weak  that  it  would  produce  no  movement  in  the  healthy 
muscles  causes  marked  response  in  the  degenerated  muscles. 
In  health  the  most  vigorous  contraction  is  obtained  by  clos- 
ing with  the  —  pole ;  in  degenerated  muscles  the  most 
vigorous  contraction  is  obtained  by  closing  with  the  +  pole. 

^  A?nerican    Text-book  of  Su7'gery. 


DISEASES  AND   INJURIES   OF  NERVES.  525 

When  voluntary  power  returns  galvanic  excitability  declines, 
but  power  is  often  nearly  restored  before  faradic  excitability 
becomes  manifest  (Buzzard). 

Treatment. — The  treatment  of  neuritis  consists  of  rest 
upon  splints,  ice-bags  early  in  the  case,  and  hot^water  bags 
later.  Massage  and  electricity  must  be  used  to  antagonize 
degeneration.  Deep  injections  of  chloroform  may  allay  pain. 
Treat  the  patient's  general  health,  especially  any  constitu- 
tional disease  or  causative  diathesis.  In  some  cases  nerve- 
stretching  is  advisable. 

Neuralg-ia  is  manifested  by  violent  paroxysmal  pain  in  the 
trajectory  of  a  nerve.  This  disease  belongs  chiefly  to  the 
physician,  except  in  very  bad  cases.  Neuralgia  of  stumps 
and  scars  belongs  to  the  surgeon,  and  is  due  to  neuromata, 
or  entanglement  of  nerve-filaments  in  a  cicatrix.  Tic 
douloureux  and  other  intractable  neuralgias  may  require 
severe  operations. 

Treatment  of  Neuralgia  of  Stumps. — Excise  the  scar ;  find 
the  bulbous  end  of  the  nerve  and  cut  it  off.  In  some  cases 
re-amputation  is  performed.  In  entanglement  of  a  nerve  in 
a  scar,  remove  a  portion  of  the  nerve  above  the  scar. 

2.  Wounds  and  Injuries  of  Nerves. 
Section  of  Nerves  (as  from  an  incised  wound). — In  nerve- 
section  the  entire  peripheral  portion  of  the  nerve  degenerates 
and  ceases  structurally  to  be  a  nerve  in  a  few  weeks,  but  after 
many  months,  or  even  after  years,  the  nerve  again  regenerates 
— with  difficulty,  if  union  of  the  ends  has  not  taken  place,  with 
much  greater  ease  if  the  ends  have  united.  The  proximal 
end  only  suffers  in  the  portion  immediately  adjacent  to  the 
section  ;  it  degenerates,  but  rapidly  regenerates,  and  a  bulb 
or  enlargement  composed  of  fibrous  tissue  and  small  nerve- 
fibres  forms  just  above  the  line  of  section  ;  this  bulb  adheres 
to  the  perineural  tissues.    Union  of  a  divided  nerve  is  brought 


526  A   MANUAL    OF  SURGERY. 

about  by  the  projection  of  an  axis-cylinder  from  each  end 
and  the  fusion  of  these  cyHnders.  The  nearer  the  two  ends 
are  to  each  other,  the  better  is  the  chance  of  union. 

Symptoms. — Pronounced  changes  occur  in  the  trajectory 
of  a  divided  nerve.  The  muscles  degenerate,  atrophy  and 
shorten,  and  show  the  reactions  of  degeneration.  When 
union  of  the  nerve  occurs  the  muscles  are  restored  to  a 
normal  condition.  If  the  nerve  contains  sensory  fibres,  com- 
plete anaesthesia  (to  touch,  pain,  and  temperature)  usually 
follows  its  division,  but  if  a  part  is  supplied  by  another  nerve 
as  well  as  by  the  divided  one,  anaesthesia  may  not  be  com- 
plete. Trophic  changes  arise  in  the  paralyzed  parts.  Among 
these  changes  are  muscular  atrophy,  glossy  skin,  cutaneous 
eruptions,  ulcers,  dry  gangrene,  painless  felons,  falling  of  the 
hair,  brittleness,  furrowing,  or  casting  off  of  the  nails,  joint- 
inflammations,  and  ankylosis.  Immediately  after  nerve-sec- 
tion vaso-motor  paralysis  comes  on,  and  for  a  itw  days  the 
paralyzed  part  presents  a  temperature  higher  than  normal. 
The  diagnosis  as  to  which  nerve  is  cut  depends  upon  a  study 
of  the  distribution  of  paralysis  and  anaesthesia.^ 

Treatment. — In  all  recent  cases  of  nerve-section,  suture 
the  ends.  If  the  patient  is  not  seen  until  long  after  the 
accident,  incise  and  apply  sutures  (secondary  sutures) ;  '\{ 
the  .nerve  cannot  be  found,  extend  the  incision,  find  the 
trunk  above  and  trace  it  down,  and  find  the  trunk  below 
and  follow  it  up.  Even  after  primary  suture  loss  of  function 
is  bound  to  occur  for  a  time.  After  secondary  suture  sensa- 
tion may  return  in  a  few  days,  but  it  may  not  return  until 
after  a  much  longer  period  ;  in  any  case  muscular  function  is 
not  restored  for  months.  In  partial  section  of  a  nerve  the 
ends  should  be  sutured. 

Pressure  upon  nerves  may  arise  from  callus,  scars,  pres- 
sure of  a  dislocated  bone  or  a  tumor,  or  pressure  from  an 

1  See  Bowlby  on  Injuries  of  Nerves. 


DISEASES  AND   INJURIES   OF  NERVES.  527 

external  body.  The  symptoms  may  be  anaesthetic,  paralytic, 
and  trophic.  The  treatment  is  as  follows  :  Remove  the 
cause  (reduce  a  dislocated  bone,  chisel  away  callus,  excise 
a  scar,  etc.) ;  then  employ  massage,  douches,  and  electricity. 

Contusion  of  Nerves. — The  symptoms  of  contusion  of 
nerves  may  be  identical  with  those  of  section.  Sensation  or 
motion,  or  both,  may  be  lost.  The  case  may  get  well  in  a 
short  time,  or  the  nerve  may  degenerate  as  after  section. 
The  treatment  at  first  is  rest,  and  later  electricity,  massage, 
frictions,  and  the  douche. 

Punctured  "Wounds  of  Nerves. — The  symptoms  of  punc- 
tured wounds  of  nerves  may  be  partly  irritative  (hyperaesthe- 
sia,  acute  pam,  and  muscular  spasm)  and  partly  paralytic 
(anaesthesia,  muscular  wasting,  and  paralysis).  The  treat- 
ment is  the  same  as  that  for  contusion. 

3.  Operations  upon  Nerves. 
Neurorrhaphy,  or  Nerve-suture. — When  a  nerve  is  com- 
pletely or  partially  divided  by  accident,  it  should  be  sutured. 
The  instruments  required  are  an  Esmarch  apparatus,  a 
scalpel,  blunt  hooks,  dissecting-forceps,  haemostatic  forceps, 
curved  needles  or  sewing-needles,  a  needle-holder,  and  cat- 
gut or  kangaroo    tendon.      In    primary 

suture    render   the    part    bloodless   and 

aseptic.     Enlarge  the  incision  if  neces-      

sary.    If  the  ends  can  readily  be  approx- 
imated, pass  two  or  three  sutures  through         ^^^-  120.— Nerve-suture. 

both  the  nerve  and  its  sheath  and  tie  them  (Fig.  120). 
If  the  ends  cannot  be  approximated,  stretch  each  end  and 
then  suture.  Remove  the  Esmarch  band,  arrest  bleeding, 
suture  the  wound,  dress  antiseptically,  and  put  the  part  in 
a  relaxed  position  on  a  splint.  After  union  of  the  wound 
remove  the  splint  and  use  massage,  frictions,  electricity, 
and   the    douche.     The   operation  in   some  instances  fails, 


>••  c 


528  A   MANUAL    OF  SURGERY. 

but  in  many  cases  succeeds.  In  some  few  cases  sensation 
returns  in  a  few  days,  but  in  most  cases  does  not  return 
for  many  weeks  or  months.  Sensation  is  restored  before 
motor  power.  Secondary  suture  is  performed  upon  cases 
long  after  division  of  a  nerve.  The  part  is  rendered  aseptic 
and  bloodless ;  an  incision  is  made ;  the  bulbous  proximal 
end  is  easily  found  and  loosened  from  its  adhesions ;  the 
shrunken  distal  end  is  sought  for  and  loosened  up  (it  may 
be  necessary  to  expose  the  nerve  below  the  wound  and  trace 
its  trunk  upward) ;  the  entire  bulb  of  the  proximal  end  is 

cut  off;  about  one-quarter  of  an  inch 

jj  , ,rj  of  the  distal  end  is  removed  (Keen) ; 

^\ap.  each  end  is  stretched,  and  the  ends 

^  are  approximated  and  sewn  together. 
If  even  stretching  does  not  permit 
of    approximation,    adopt   one    of 
Fig.  12 1. -Suture of  a  Nerve  by    Bowlby's  expedients  (Fipf.  I2i)  or 

Splitting  the  Ends  (Beach).  .  V       t>  / 

graft  a  bit  of  nerve  from  a  recently- 
amputated  limb  or  from  a  lower  animal  (it  makes  no  dif- 
ference as  to  whether  the  grafted  nerve  were  motor,  sensory, 
or  mixed).  Von  Bergmann  suggests  shortening  the  limb 
by  excising  a  piece  of  bone. 

Neurectasy,  Neurotomy,  and  Neurectomy. — Neurectasy^ 
or  nerve-stretching,  may  be  applied  to  motor,  sensory,  or 
mixed  nerves.  A  nerve  can  be  stretched  about  one-twentieth 
of  its  length  (Vogt).  Neurectasy  has  been  employed  for 
neuralgia,  neuritis,  muscular  spasm,  hyperaesthesia,  anaes- 
thesia, painful  ulcer,  and  the  pains  of  locomotor  ataxia. 
The  operation,  which  was  once  the  fashion,  seems  to  benefit 
some  cases,  but  it  is  not  now  thought  so  highly  of  as  formerly. 
The  incision  for  neurectasy  is  identical  with  the  incision  for 
neurectomy  or  neurotomy  of  the  same  nerve.  Neurotomy^ 
or  section  of  a  nerve,  is  only  performed  upon  small  and 
purely  sensory  nerves.     It  is  performed  chiefly  for  peripheral 


DISEASES  AND   INJURIES   OF  NERVES.  529 

neuralgia  or  for  some  other  painful  malady.  Neurectomy ,  or 
excision  of  a  portion  of  a  nerve-trunk,  is  only  applicable  to 
sensory  nerv^es  and  to  painful  affections. 

Stretching"  of  the  Sciatic  Nerve. — Some  surgeons  stretch 
the  sciatic  nerve  by  anaesthetizing  the  patient  and  holding  the 
leg  and  thigh  in  line,  strong  flexion  being  made  upon  the 
hip,  the  entire  lower  extremity  being  used  as  a  lever  (Keen). 
This  rnethod,  which  has  caused  death,  inflicts  needless 
damage,  and  the  operative  plan  is  safer  and  better.  The 
instruments  required  are  a  scalpel,  haemostatic  forceps,  dis- 
secting forceps,  an  Allis  dissector,  retractors,  and  a  scale 
with  a  handle  and  a  hook.  The  patient  lies  prone,  the 
thighs  and  legs  being  extended.  An  incision  four  inches 
in  length  is  made  a  little  external  to  the  middle  of  the  thigh, 
and  going  at  once  through  the  deep  fascia ;  the  biceps  is 
found  and  is  drawn  outward  ;  the  nerve  is  found  between 
the  retracted  biceps  on  the  outside  and  the  semitendinosus 
on  the  inside,  resting  upon  the  adductor  magnus  muscle. 
The  nerve,  which  is  caught  up  by  the  finger,  is  first  pulled 
down  from  the  spine  and  then  up  from  the  peripher}',  and 
finally  the  hook  of  the  scale  is  inserted  beneath  the  trunk 
and  the  nerve  is  stretched  to  the  extent  of  forty  pounds. 
Very  rarely  is  a  single  ligature  needed.  The  wound  is 
sutured  and  dressed.  If  the  incision  is  made  higher  up, 
just  below  the  gluteo-femoral  crease,  the  sciatic  nerve  will 
be  found  just  by  the  outer  border  of  the  biceps. 

Neurectomy  of  the  Infraorbital  Nerve. — The  instru- 
ments required  in  this  operation  are  a  scalpel,  dissecting-for- 
ceps,  aneurysm-needle,  haemostatic  forceps,  blunt  hooks, 
an  Allis  dissector,  and  metal  retractors.  The  patient  lies 
upon  his  back,  the  head  being  a  little  raised  by  pillows.  The 
surgeon  stands  to  the  outside  of,  and  faces,  the  patient.  A 
curved  incision  one  and  a  half  inches  long  is  made  below 
the  lower  border  of  the  orbit.  The  nerve  lies  in  a  line 
34 


530  A   MANUAL    OF  SURGERY. 

dropped  from  the  supraorbital  notch  to  between  the  two 
lower  bicuspid  teeth.  The  nerve  is  found  upon  the  levator 
labii  superioris  muscle,  and  a  piece  of  silk  is  passed  under 
the  nerve  by  an  aneurysm-needle  and  firmly  fastened.  The 
upper  border  of  the  incision  is  drawn  upward  ;  the  periosteum 
of  the  floor  of  the  orbit  is  elevated  and  held  by  a  retractor ; 
the  roof  of  the  infraorbital  canal  is  broken  through  ;  the  nerve 
is  picked  up  far  back  with  the  blunt  hook  and  is  divided  with 
scissors,  and  the  entire  nerve  is  drawn  out  by  making  traction 
upon  the  silk.  The  bleeding  in  the  orbit  is  checked  by  pres- 
sure.    The  wound  is  stitched  without  drainage. 

Neurectomy  of  the  Supraorbital  Nerve. — In  this  opera- 
tion, shave  off  the  eyebrow.  The  instruments  required  and 
the  position  of  the  patient  are  as  for  the  operation  upon  the 
infraorbital  nerve.  A  curved  incision  one  inch  long  discloses 
the  nerve  as  it  emerges  from  the  supraorbital  notch  or  fora- 
men at  the  junction  of  the  inner  and  middle  thirds  of  the 
eyebrow.  The  nerve  is  pulled  forward  and  cut  off  above 
and  below. 

XXII.  DISEASES  AND  INJURIES  OF  THE  HEAD. 
I.  Diseases  of  the  Head. 

In  approaching  cases  of  brain  disorder,  first  endeavor  to 
locate  the  seat  of  the  trouble ;  next,  to  ascertain  the  nature 
of  the  lesion  ;  and  finally,  to  determine  the  best  plan  of 
treatment,  operative  or  otherwise.  In  all  operations  upon 
the  brain  the  surgeon  must  be  able  to  determine  accurately 
the  situations  of  certain  fissures  and  convolutions,  the  find- 
ing of  the  situations  of  these  convolutions  and  fissures  com- 
prising the  science  of  cranio-cerebral  topography. 

The  regional  terms  used  in  cranio-cerebral  topography 
are  derived  from  Broca  (Fig.  122).  The  fissures  and  convo- 
lutions of  the  brain  are  shown  in  Figures  123,  124,  and  125. 
Th.Q  fissure  of  Bichat  is  marked  by  a  line  on  each  side  drawn 


DISEASES  AND   INJURIES   OF   THE   HEAD. 


531 


from  the  inion  to  the  external  auditory  process.  A  Hne 
from  the  glabella  to  the  inion  overlies  the  median  fissure 
and  the  superior  longitudinal  sinus.  The  fissure  of  Rolando 
begins   in   the    median   line,  half  an    inch  posterior  to   the 

middle  of  the  distance  between 
the  inion  and  glabella  (Keen).  This 
fissure  runs  downward  and  forward 
at  an  angle  of  67°  for  a  distance 
of  three  and  three-eighths  inches. 
Chiene  finds  the  fissure  of  Rolando 
by  the  following  method :  He  takes 


Fig.  122. — Skull  showing  the  Points 
named  by  Broca  :  As,  asterion  (junc- 
tion of  the  occipital,  parietal,  and 
temporal  bones  I ;  Basion,  middle  of 
anterior  wall  of  foramen  magnum ; 
B,  bregma  (junction  of  the  sagittal 
and  coronal  sutures)  ;  G,  ophryon 
(on  a  level  with  the  superior  border 
of  the  eyebrows,  and  corresponding 
nearly  to  the  glabella,  the  smooth 
swelling  between  the  eyebrows) ;  g, 
gonion  (angle  of  the  lower  jaw);  /, 
inion  (external  occipital  protuber- 
ance); L,  lambda  (junction  of  sagit- 
tal and  lambdoidal  sutures)  ;  N,  na- 
sion  (junction  of  the  nasal  and 
frontal):  Ob,  obelion  (the  sagittal 
suture  between  the  parietal  foram- 
ina);  P,  pterion  (point  of  junction 
of  great  wing  of  sphenoid  and  the 
frontal,  parietal,  and  squamous  bones. 
This  may  be  H -shaped  or  K -shaped, 
or  "  retourne,"  in  wTiich  the  frontal 
and  temporal  just  touch) ;  S,  ste- 
phanion  (or,  better,  the  superior  ste- 
phanion,  intersection  of  ridge  for 
temporal  fascia  and  coronal  suture) ; 
S' ,  inferior  stephanion  (intersection 
of  ridge  for  temporal  muscle  and 
coronal  suture  i. 


Fig.  123.— View  of  the  Brain  from  Above  (Ecker). 


a  square  piece  of  paper  and  folds  it  into  a  triangle  (Fig. 
126,  i);  the  angle  b  a  c  of  this  triangle  is  45°;  the  edge  da 
is  folded  back  on  the  dotted  line  ae;  the  angle  dae 
equals  half  of  45°,  or  22.5°,  and  the  angle  cae  equals  the 
same  (Fig.  126,  2);   unfold  the  paper  in  the  line  c  a  ;  in  the 


532 


A    MANUAL    OF  SURGERY. 


figure  thus  formed  BAC=45°and  eac  — 22.5°;  eab--67.5°, 
which  is  the  angle  desired.  Place  the  point  a  in  the  mid- 
line of  the  head, 
over  the  point  of 
origin  of  the  Ro- 
landic  fissure ;  the 
side  A  B  is  laid  along 
the  middle  line  of  the 
head,  and  the  line  a  e 
corresponds  to  the 
fissure  of  Rolando/ 
Horsley  determines 
the  situation  of  the 
Rolandic  fissure  by 
the  use  of  his  metal 
cyrto meter  (Fig. 
127).  He  places  the 
point  marked  zero  over  the  inio-glabellar  line  and  mid- 
way  between   the    inion    and   the    glabella.      To    find  the 


Fig.  124. — Outer  Surface  of  the  Left  Hemisphere  of  the 
Brain  (Ecker). 


Fig.  125.— Inner  Surface  of  the  Right  Hemisphere  of  the  Brain  (Ecker). 

fissure  of  Sylviits  (Fig.  124,  S,s',s"),  draw  a  line  from  the 
external  angular  process  to  the  occipital  protuberance.  The 
fissure  of  Sylvius  begins  on  this  line   one  and  one-eighth 

^  American  Text-book  of  Surgery. 


DISEASES  AND   INJURIES   OF  THE  HEAD. 


533 


inches  behind  the  external  angular  process ;  the  main 
branch  of  the  fissure  runs  toward  the  parietal  eminence ; 
the  ascending  branch  of  the  fissure  corresponds  to  the 
squamoso-sphenoidal  suture,  and  continues  upward  in  the 
same  line  half  an  inch  above  the  suture.  The  preccntral 
sulcus  (Fig.   124,  f)    limits  anteriorly  the  ascending  frontal 


C  E  Be  E  B    C  ^ 

Fig.  126. — Chiene's  Method  of  Fixing  Position  of  the  Rolandic  Fissure  {Am.  Text-book 
of  Surgery). 

convolution;  it  runs  parallel  with  and  just  behind  the 
coronal  suture,  and  a  finger's  breadth  in  front  of  the  fissure 
of  Rolando.  The  intraparietal fissure  (Figs.  123,1 24,  ip)  limits 
the  motor  region  posteriorly.  It  begins  opposite  the  junc- 
tion of  the  lower  and  middle  thirds  of  the  fissure  of  Rolando, 

K.Jl.,.6|.,.S|...^|...3|...a|....i.,p|.  ■ 


Fig.  127. — Horsley's  Cyrtometer. 

passes  upward  in  a  line  parallel  with  the  longitudinal  fissure 
and  midway  between  the  Rolandic  fissure  and  the  parietal  emi- 
nence, passes  by  the  parieto-occipital  fissure,  and  downward 
and  backward  into  the  occipital  lobe  (Keen).     The  motor 


534 


A   MANUAL    OF  SURGERY. 


areas,  which  on  the  outer  surface  are  adjacent  to  the  fissure 
of  Rolando,  are  shown  in  Figures  123  and  124.  The  supe- 
rior longitudinal  sinus  is  overlaid  by  a  line  from  the  inion 
to  the  glabella.  The  lateral  sinus  is  indicated  by  a  line  run- 
ning from  the  occipital  protuberance  horizontally  outward  to 

a  point  one  inch  posterior  to  the 
external  auditory  meatus,  and 
from  this  point  by  a  second  line 
dropped  to  the  mastoid  process. 
The  supra-meatal  triangle  of  Mac- 
ewen  is  bounded  by  the  posterior 
root  of  the  zygoma,  the  poste- 
rior bony  wall  of  the  auditory 
meatus,  and  a  line  joining  the 
two.  Figure  128  shows  clearly 
the  main  points  of  cranio-cerebral 

Fig.   128. — Head.  Skull,  and  Cere-  ,  ■,  i   ,     •         i    i  ^11 

bral  Fissures  (adapted  from  Marshall  tOpOgraphy,  ObtameO  by  niCthodS 
by  Hare) :    B  corresponds  to  Broca's  ,   ,  .  . 

convolution:    EAP,    external    angular  apprOVCd    by   maUy   SClCUtlStS. 
process;   FR,  fissure  of  Rolando ;   IF,  n       1  r^        1  t-i 

inferior  frontal  sulcus;   I PF,  intrapari-  DlSGaSGS      Of     the      Scalp. 1  hC 

etal  sulcus  ;  MMA,  middle  meningeal 

artery;    OPr,  occipital  protuberance ;  SCalp      is     COmpOSCd     of    skin,    Sub- 
PE,  parietal  eminence  ;   POF,  parieto- 
occipital fissure  ;  SF,  Sylvian  fissure  ;  cutaneous    fat,    and    the    occipito- 

A,  its  ascending  limb ;  TS,  tip  of  tem- 

poro-sphenoidai  lobe.   The  pterion  (to   frontalis  musclc  and  aponcurosis. 

the  leit  of  B)  is  the  region  where  three  •"■ 

sutures  meet,  viz..  those  bounding  the   ^\^q  scalo  is  liable  to  inflammation 

great  wing  of   the   sphenoid   where  it  ^ 

poi-al  bonel"^""^^''  parietal,  and   tem-     fj-^^l  VarioUS    CaUSCS,  and    tO    Othcr 

diseases,  namely :  tumors,  cysts, 
warts,  moles  (local  cutaneous  hypertrophies),  cirsoid  aneurysm 
(p.  231),  naevi,  and  lupus.  Abscesses  of  the  scalp  are  com- 
mon. If  an  abscess  forms  beneath  the  pericranium,  the 
pus  diffuses  over  the  area  of  one  bone,  being  limited  by 
the  attachment  of  the  pericranium  in  the  sutures.  If  an 
abscess  forms  in  the  tissue  between  the  occipito-frontalis 
and  the  pericranium,  it  is  widely  diffused.  Treves  calls  this 
subaponeurotic  connective  tissue  "the  dangerous  area." 
Abscess   of  the   subcutaneous   tissue   is  apt  to  be   limited 


DISEASES  AND   INJURIES   OF   THE  HEAD.  535 

because  of  the  great  amount  of  fibrous  tissue.  Abscess  is 
treated  by  instant  incision  at  the  most  dependent  part,  anti- 
septic irrigation,  and  drainage. 

Diseases  and  Malformations  of  the  Bones  of  the  Skull. 
— The  bones  of  the  skull  are  liable  to  caries,  necrosis,  oste- 
itis, periostitis,  atrophy,  hypertrophy,  tumors,  etc.  (See  Dis- 
eases of  Bones.) 

Microcephalus. — By  microcephalus  is  meant  unnatural 
smallness  of  the  head  due  to  imperfect  development.  It  is 
a  cause  or  a  frequent  associate  of  idiocy.  A  child  may  be 
born  with  a  skull  completely  ossified  even  at  the  fontanelles, 
or  the  ossification  may  become  complete  soon  after  birth. 
In  microcephalus  the  face  is  apt  to  be  fairly  well  developed; 
the  jaws  are  prominent ;  the  forehead  is  flat ;  the  cranmm 
and  brain  are  small;  the  convolutions  of  the  brain  are 
simpler  than  is  natural ;  there  is  apt  to  be  marked  asym- 
metry of  the  two  sides  of  the  brain ;  internal  hydrocephalus 
may  exist;  areas  of  sclerosis  and  atrophy  are  common; 
porencephaly  is  not  unusual.  Some  patients  have  perfect 
motor  power ;  others  are  slow  and  inco-ordinate.  Epilepsy, 
chorea,  and  athetosis  frequently  complicate  the  case. 

Treatment. — Skilled  training  in  a  school  for  the  feeble- 
minded or  in  an  institution  for  idiots  is  necessary  in  treating 
microcephalus.  Some  surgeons  advise  that  first  a  craniec- 
tomy be  performed  (see  Opevations  on  Skull  and  Brahi). 
The  late  Prof  Agnew,  taking  the  view  that  the  growth  of 
soft  parts  moulds  hard  parts,  and  that  the  fault  is  with  the 
brain,  and  not  with  the  skull,  maintained  that  the  surgeon 
might  as  well  cut  a  piece  out  of  a  turtle's  shell  to  permit 
growth  of  the  turtle  as  to  cut  a  piece  out  of  the  skull  to 
permit  growth  of  the  brain.  Prof  Keen  says,  "  While  there 
is  no  doubt  that,  as  a  rule,  the  growth  of  the  encasing  hard 
parts  is  dominated  by  the  growth  of  the  contained  soft  parts, 
yet  it  is  very  possible  that  while  a  healthy  brain  may  over- 


536  A   MANUAL    OF  SURGERY. 

come  the  normal  resistance  of  the  skull,  a  brain  with  feeble 
powers  of  development  may  be  arrested  in  its  growth  by  the 
slight  resistance  offered  by  the  skull."  Prof  Keen  further 
says,  "  Whether  the  operation  will  stand  the  test  of  time 
cannot  yet  be  determined,  but  considerable  initial  improve- 
ment has  followed  in  a  number  of  cases." 

Diseases  and  Malformations  Involving"  the  Brain. — 
Meningocele  is  a  congenital  protrusion  of  the  cerebral 
membranes  through  a  bony  aperture,  the  sac  containing 
some  extra-cerebral  fluid.  Meningocele  feels  and  looks  like 
a  cyst  (is  translucent  and  fluctuates) ;  it  does  not  usually 
pulsate,  it  has  a  small  base,  it  becomes  tense  on  forcible 
expiration,  and  it  may  be  reduced. 

Encephalocele  is  a  congenital  protrusion  not  only  of 
membranes,  but  also  of  a  portion  of  the  brain  as  well,  the 
sac  containing  some  extra-cerebral  fluid.  Encephalocele  is 
small,  opaque,  does  not  fluctuate,  has  a  broad  base,  does 
pulsate,  becomes  tense  on  forced  expiration,  and  attempts 
at  reduction  cause  pressure-symptoms. 

Hydrencephalocele  is  a  congenital  protrusion  of  mem- 
branes and  brain-substance,  the  interior  of  the  mass  com- 
municating with  the  ventricles  and  containing  ventricular 
fluid.  This  is  the  most  frequent  and  the  most  dangerous 
form.  Hydrencephalocele  is  larger  than  a  meningocele,  is 
translucent,  fluctuates,  rarely  pulsates,  is  pedunculated,  is 
rendered  a  little  tense  on  forced  expiration,  and  cannot  be 
reduced.^ 

Treatment. — For  hydrencephalocele  nothing  can  be  done, 
and  early  death  is  inevitable.  In  rare  instances  an  enceph- 
alocele is  converted  into  a  meningocele,  and  the  bony 
aperture  closes,  thus  bringing  about  a  cure.  Among  the 
expedients  for  treating  meningocele  and  encephalocele  are 
electrolysis,    injection   of   Morton's    fluid   (gr.   x   of  iodine, 

^  American    Text-book  of  Surgery. 


DISEASES  AND  INJURIES   OF   THE  HEAD.  537 

gr.  XXX  of  iodide  of  potassium,  5J  of  glycerin),  pressure, 
and  excision. 

Hydrocephalus. — In  external  hydrocephalus  the  fluid  is 
between  the  membranes  and  the  brain ;  in  internal  hydro- 
cephalus the  fluid  is  in  the  ventricles.  Hydrocephalus  may 
be  acute  or  chronic,  congenital  or  acquired. 

Acute  hydrocephalus,  which  results  from  meningitis 
(usually  from  tubercular  meningitis),  is  usually  internal,  but 
may  be  external.  The  symptoms  are  headache,  elevated 
temperature,  delirium,  stupor,  convulsions,  paralysis,  and 
choked  disk. 

Treatment  of  acute  hydrocephalus  is  of  no  avail.  Tapping 
of  the  ventricles  may  be  tried. 

Chronic  hydrocephalus  is  usually  congenital.  The  cra- 
nium enlarges  enormously  and  the  bones  of  the  skull  are 
widely  separated.  The  broad  forehead  overhangs  the  eyes. 
The  child  is  an  idiot,  and  very  often  does  not  learn  to  walk 
or  to  talk.  Convulsions  and  palsies  are  common,  and  blind- 
ness is  frequent.     Such  children  usually  die  young. 

The  treatment  of  chronic  hydrocephalus  is  rarely  of  much 
avail.  Pressure  by  strapping  with  adhesive  plaster  has  been 
tried.  Tapping  through  a  fontanelle  may  be  performed  by 
means  of  a  trocar  (only  sij  or  5iij  being  drawn  at  a  time).  If 
much  fluid  is  drawn,  the  head  must  be  strapped  afterward. 
If  the  skull  ossifies,  the  lateral  ventricles  may  be  tapped.  It 
has  been  proposed  to  drain  by  tapping  the  theca  of  the  spinal 
cord  (Quincke). 

2.  Injuries  of  the  Head. 

Cephalheematoma  (caput  succedaneum),  which  is  a  col- 
lection of  bloody  serum  under  the  scalp  of  a  new-born 
child,  results  from  the  pressure  of  labor.  No  treatment  is 
required. 

Scalp-wounds  are  treated  as  are  other  wounds.     A  large 


538  A   MANUAL    OF  SURGERY. 

piece  of  scalp  with  only  a  narrow  pedicle  may  not  slough  ; 
hence  try  to  save  any  piece  that  has  an  attachment.  Always 
shave  a  wide  area  and  disinfect  the  wound  thoroughly. 
Stitch  the  wound  with  silkworm  gut.  If  drainage  is  required, 
use  a  few  strands  of  horsehair. 

Contusions  of  the  Head. — Scalp-swelling  from  hemor- 
rhage is  usually  considerable.  The  patient  may  be  stunned 
or  dazed.  The  swelling  of  haematoma  must  not  be  mistaken 
for  fracture  with  depression.  In  haematoma  there  is  a  cen- 
tral depression,  hard  pressure  finds  bone  on  a  level  with  the 
general  contour  of  the  bone,  and  the  margin  of  a  haematoma 
is  circular,  is  not  quite  hard,  and  is  elevated  above  the  gen- 
eral contour.  In  depressed  fracture  the  edge  is  on  a  level 
with  or  below  the  level  of  the  general  bony  contour,  and  the 
margin  is  sharp  and  irregular.  The  treatment  is  by  means 
of  pressure  and  the  use  of  lead-water  and  laudanum.  If 
suppuration  arises,  at  once  incise. 

Concussion  or  Laceration  of  the  Brain. — Prof  Keen 
says  that  there  may  be  slight  brain-injuries  which  may 
properly  be  called  *'  concussions,"  but  it  is  better  to  consider 
concussion  as  synonymous  with  laceration  of  the  brain.  The 
cause  of  concussion  is  violent  force,  either  direct  (as  a  blow 
upon  the  head)  or  indirect  (as  a  fall  upon  the  buttocks). 
This  force  shakes,  oscillates,  or  jars  the  brain  and  ruptures 
vascular  twigs,  large  vessels,  or  even  the  membranes.  In 
the  slighter  ruptures  concussion  only  exists ;  in  the  severe 
ruptures  compression  soon  arises. 

Symptoms. — In  a  mild  case  of  brain-concussion  the  patient 
may  or  may  not  fall ;  his  face  is  pale  ;  he  feels  weak,  giddy, 
nauseated,  and  confused ;  he  often  vomits,  but  soon  reacts. 
In  a  severe  case  he  lies  with  complete  muscular  relaxation, 
cold  extremities,  pale  and  cold  skin,  shallow  and  quiet 
respiration,  frequent,  small,  soft,  and  irregular  pulse  (pulse 
may  not   be    detectable),  and   fluttering   heart.     He   seems 


DISEASES  AND  INJURIES   OF  THE  HEAD.  539 

unconscious,  but  can  be  roused  to  monosyllabic  response 
by  shouting,  pinching,  or  holding  a  bright  light  near  his 
face.  The  urine  and  feces  are  often  passed  involuntarily. 
The  pupils  may  be  unaltered,  may  be  dilated  or  contracted, 
or  may  be  equal  or  unequal,  but  in  any  case  they  will  react 
to  light.  No  paralysis  exists.  The  temperature  at  first  is 
subnormal.  In  a  severe  cortical  laceration  there  will  be 
twitchings  or  even  general  convulsions,  or  the  patient  will 
lie  curled  up  with  limbs  flexed  and  eyelids  shut,  and  will 
resist  all  attempts  to  open  his  eyes  or  mouth  or  to  move  his 
limbs  (A.  Pearce  Gould).  Erichsen  called  this  condition 
**  cerebral  irritability."  As  the  patient  reacts  he  will  most 
probably  vomit.  Within  twenty-four  hours  he  usually  im- 
proves, but  is  feverish  and  complains  of  headache  and  lassi- 
tude. After  concussion  a  man's  whole  nature  may  change : 
he  may  develop  hysteria,  insanity,  or  epilepsy,  and  in  many 
cases  there  is  complaint  for  a  long  time  of  headache,  insom- 
nia, low  spirits,  and  lassitude.  If  the  patient  in  concussion 
recedes  from,  instead  of  advancing  toward,  recovery,  coma 
will  set  in  or  inflammation  will  develop.  Dr.  Keen  states 
that  the  prognosis  is  always  uncertain.  Any  concussion 
producing  unconsciousness  is  a  serious  injury,  because  con- 
siderable laceration  must  have  occurred. 

Treatment. — In  treating  brain-concussion,  bring  about 
reaction  by  the  administration  of  aromatic  spirits  of  ammo- 
nia (no  alcohol),  by  surrounding  the  patient  (who  lies  in  bed 
without  a  pillow)  with  hot  bottles,  by  the  application  of 
mustard  over  the  heart,  and  by  the  administration  of  hot 
coffee.  Place  the  patient  in  bed  in  a  quiet  room,  and  watch 
him.  For  some  days  or  for  some  weeks,  according  to  the 
case,  insist  on  an  easy  life.  Give  a  plain  diet  containing  a 
minimum  of  meat,  administer  an  occasional  purgative,  and 
secure  sleep.  If  inflammation  arises,  some  surgeons  will 
not  trephine,  but  others,  especially  if  the  damage  seems  to 


540  A   MANUAL    OF  SURGERY. 

be  localized,  incise  the  scalp  and  inspect  the  bone.  If  a 
fracture  is  discovered  and  the  symptoms  are  serious,  they 
perform  an  exploratory  trephining,  open  the  dura,  and 
secure  drainage  for  inflammatory  products. 

In  many  severe  contusions  the  surgeon  should  at  once 
incise  the  scalp  and  inspect  the  bone.  For  many  weeks 
after  a  severe  concussion  a  patient  must  be  kept  away  from 
business  and  be  watched  because  of  the  possibility  of  an 
abscess  of  the  brain  arising. 

Compression  of  the  Brain. — The  causes  of  brain-com- 
pression are  hemorrhage,  depressed  fracture,  tumor,  inflam- 
matory exudate,  pus,  and  foreign  bodies. 

Symptoms. — In  brain-compression  complete  coma  exists 
without  voluntary  movement.  The  skin  is  hot  and  per- 
spiring; the  respirations  are  slow  and  stertorous  and  the 
cheeks  flap  during  expiration ;  the  pulse  is  slow  and  full, 
and  may  be  irregular;  the  pupils  are  dilated,  and  do  not 
respond  to  light ;  there  is  usually  retention  of  urine,  and 
often  incontinence  of  feces  ;  paralysis  exists,  which  may  be 
very  limited  (monoplegia),  may  be  of  one  side  (hemiplegia), 
or  may  be  general.  In  hemorrhage  into  the  interior  of  the 
brain  the  unconsciousness  is  immediate  or  nearly  so.  In 
bleeding  from  the  middle  meningeal  artery  a  period  of  con- 
sciousness intervenes  between  the  injury  and  the  coma,  in 
which  period  blood  collects.  In  compression  from  depressed 
fracture  or  from  a  foreign  body  the  symptoms  usually  come 
on  at  once,  but  they  may  be  deferred  for  some  hours.  Com- 
pression from  inflammation  or  pus  begins  gradually  after  a 
considerable  time  has  elapsed. 

A  diagnosis  must  be  made  between  coma  due  to  brain- 
injury  and  the  comatose  conditions  of  apoplexy,  uraemia, 
opium-poisoning,  and  alcoholic  intoxication.  In  hospital 
practice  cases  of  unconsciousness  without  a  known  history 
are  frequent.     In  attempting  this  diagnosis,  examine  care- 


DISEASES  AND   INJURIES   OF   THE   HEAD.  54 1 

fully  for  any  evidence  of  traumatism,  and  inquire  as  to  how 
and  where  the  patient  was  found,  if  any  fit  occurred,  and  if 
a  bottle  or  a  pill-box  was  found  near  by  or  in  the  pockets, 
which  also  examine.  Smell  the  breath  to  notice  alcohol  or 
opium,  but  always  remember  that  a  man  may  be  stricken 
with  apoplexy  while  being  drunk,  and  may  fracture  his 
skull  by  falling  when  under  the  influence  of  opium  or  of 
alcohol.  Draw  the  urine  with  the  catheter  if  any  water  is  in 
the  bladder,  examine  the  urine  for  albumin  and  alcohol, 
and  take  the  specific  gravity.  In  doubtful  cases  of  coma, 
use  the  ophthalmoscope.  In  post-epileptic  coma  the  tempera- 
ture is  never  below  normal,  there  are  no  unilateral  symptoms, 
the  condition  resembles  sleep,  and  the  patient  can  be  aroused. 
Hysterical  coma  occurs  in  boys  and  women  ;  there  are  no  ob- 
jective symptoms,  and  the  patient,  though  swallowing  what  is 
put  into  his  mouth,  cannot  be  roused  (Gowers).  In  iircemia, 
besides  the  condition  of  the  urine  (and  always  remember 
that  a  person  with  albuminuria  is  apt  to  develop  apoplexy), 
there  is  a  persistent  subnormal  temperature,  and  convulsions 
are  prone  to  occur.  There  is  cedema  of  the  legs,  and 
paralysis  and  stertor  are  absent.  In  apoplexy  hemiplegia 
exists,  and  the  initial  temperature  is  for  a  short  time  sub- 
normal. A  single  convulsion  may  have  ushered  in  the  case. 
Alcoholic  iinconscioiisness  is  often  diagnosticated  when  apo- 
plexy really  exists.  A  man  will  smell  of  alcohol  who  has 
had  one  drink,  but  one  drink  will  not  produce  coma;  hence 
the  smell  of  alcohol  is  not  conclusive.  In  any  case  of 
doubt  some  hours  of  watching  will  clear  up  the  diagnosis. 
Regard  a  doubtful  case  as  serious  until  the  truth  is  clear. 
In  opium-poisoning  the  pupils  are  contracted  to  a  pin-point, 
the  respirations  are  usually  slow,  shallow,  and  quiet,  but  may 
be  stertorous,  but  there  is  no  paralysis.  Always  remember 
that  hemorrhage  into  the  pons  will  produce  pin-point  pupils, 
but  it  also  causes  paralysis  (crossed  paralysis  if  in  the  lower 


542  A   MANUAL    OF  SURGERY. 

half  of  the  pons)  and  high  temperature  with  sweating.  In 
opium-poisoning  the  temperature  is  subnormal.  In  diabetic 
coma  the  pupils  will  react  to  a  very  bright  light,  the  tempera- 
ture is  subnormal,  and  the  breath  and  the  urine  smell  like 
chloroform. 

Treatment. — The  treatment  of  brain-compression  depends 
on  the  cause.  Hemorrhage  (extradural  or  subdural)  requires 
trephining  and  arrest  of  bleeding  ;  coma  from  depressed  frac- 
ture demands  trephining  and  elevation  ;  foreign  bodies  must 
be  removed ;  abscesses  must  be  evacuated ;  some  tumors  are 
to  be  removed. 

Intracranial  hemorrhag-e  may  be  either  spontaneous  or 
traumatic.  In  the  vast  majority  of  instances  spontaneous 
hemorrhage  comes  from  the  lenticulo-striate  artery  (Char- 
cot's artery  of  cerebral  hemorrhage),  and  produces  apoplexy, 
a  disease  belonging  to  the  physician  except  in  some  ingra- 
vescent cases,  for  which  ligation  of  the  carotid  on  the  same 
side  as  the  rupture  is  indicated.  Traumatism  during  delivery 
is  a  not  unusual  cause  of  hemorrhage  from  the  middle  men- 
ingeal artery  (Richardiere).  A  traumatic  hemorrhage  may 
take  place  (i)  between  the  bone  and  the  dura  {extradural) ; 
(2)  between  the  dura  and  the  brain  [subdural) ;  and  (3)  in 
the  brain-substance   [cerebral). 

(i)  Extradural  hemorrhag-e  arises  from  the  middle 
meningeal  or,  more  often,  from  one  of  its  branches.  It  is 
usually,  but  not  always,  accompanied  by  fracture ;  in  fact, 
in  some  cases  not  even  a  bruise  can  be  found.  The  accident 
may  or  may  not  cause  temporary  unconsciousness,  but  even 
if  it  does,  from  this  unconsciousness  the  patient  almost  always 
reacts,  and  there  is  a  distinct  period  of  consciousness  between 
the  accident  and  the  lasting  coma,  the  coma  being  due  to 
pressure  from  a  continually  increasing  mass  of  extravasated 
blood.  If  the  main  trunk  or  a  large  branch  is  ruptured,  the 
period  of  consciousness  is  short ;  if  a  small  branch  is  rup- 


DISEASES  AND   INJURIES   OF   THE   HEAD.  543 

tured,  the  period  of  consciousness  is  prolonged  for  hours 
or  perhaps  for  days.  The  other  signs  of  this  condition  are 
paralysis  of  the  side  opposite  the  blood-clot  (not  necessarily 
of  the  side  opposite  the  injury,  for  the  artery  may  rupture 
from .  contre-coup  on  the  uninjured  side);  this  paralysis  is 
apt  at  first  to  be  localized,  but  it  gradually  and  progressively 
widens  its  domain.  If  the  clot  extends  toward  the  base,  the 
pupil  on  the  same  side  as  the  clot  ceases  to  react  and  dilate, 
and  if  it  be  the  left  side,  aphasia  is  noted.  The  pulse  becomes 
frequent ;  the  breathing  becomes  stertorous ;  the  tempera- 
ture rises,  that  of  the  paralyzed  side  exceeding  that  of  the 
sound  side ;  and  in  a  compound  fracture  the  pressure  of 
escaping  blood  may  force  brain-matter  out  of  the  wound 
(Keen). 

Treatment. — In  treating  extradural  hemorrhage,  localize 
the  clot,  not  by  the  seat  of  the  wound  or  contusion,  but 
entirely  by  the  symptoms.  Trephine  one  and  one-fourth 
inches  back  of  the  external  angular  process,  at  the  level  of 
the  upper  border  of  the  orbit  (Kronlein).  If  this  incision 
does  not  show  the  clot,  trephine  again  at  the  level  of  the 
upper  border  of  the  orbit  and  just  below  the  parietal  emi- 
nence. The  first  incision  gives  access  to  the  trunk  and  to 
the  anterior  branch ;  the  second  incision  exposes  the  poste- 
rior branch.  If  signs  indicate  that  the  clot  is  travelling  to 
the  base,  the  trephine  should  be  used  half  an  inch  lower 
than  the  first  indicated  point.  Proceed  to  arrest  bleeding  as 
directed  on  page  252,  and  always  drain. 

(2)  Subdural  hemorrhage  is  usually  due  to  depressed 
fracture  and  rupture  of  the  middle  cerebral  artery  or  of 
a  number  of  small  vessels.  The  symptoms  are  identical  with 
those  of  extradural  bleeding. 

The  tyeatment  is  trephining  at  the  first  hemorrhagic  point, 
enlarging  the  opening  with  a  rongeur  upward  and  back- 
ward, opening  the  dura,  turning  out  the  clot,  ligating  the 


544  ^    MANUAL    OF  SURGERY. 

bleeding  point,  elevating  any  depression  of  bone,  draining, 
and  stitching  the  dura  with  catgut.  Hemorrhage .  from 
internal  pachymeningitis  requires  the  same  treatment. 

(3)  Cerebral  Hemorrhage. — The  symptoms  of  cerebral 
hemorrhage  are  identical  with  those  of  apoplexy.  The  treat- 
ment is  the  same  as  that  for  apoplexy,  except  in  ingravescent 
cases,  when  the  common  carotid  on  the  same  side  as  the  clot 
should  be  ligated. 

Rupture  of  a  sinus  usually  arises  from  compound  frac- 
ture or  during  a  brain-operation.  The  treatment,  if  the 
rupture  happens  from  fracture,  is  trephining.  Enlarge  the 
opening  by  the  rongeur,  pack  with  one  large  piece  of  iodo- 
form gauze,  or  catch  the  rent  with  haemostatic  forceps,  leav- 
ing them  in  place  for  three  or  four  days,  or  apply  a  lateral 
ligature.  Elevate  depressed  bone.  In  rupture  during  an 
operation,  control  hemorrhage  by  packing. 

Fractures  of  the  skull  may  be  simple,  compoimd,  depressed, 
noji-depressed,  or  punctured.  They  are  divided  into  frac- 
tures of  the  vault,  usually  due  to  direct  force,  and  fractures 
of  the  base,  due  to  extension  of  fractures  of  the  vault,  to 
indirect  violence  (a  fall  upon  the  feet,  the  buttocks,  or  the 
vault),  to  forcing  of  the  condyles  of  the  lower  jaw  against  or 
through  the  base,  or  to  foreign  bodies  breaking  through  the 
orbit  or  the  roof  of  the  nostrils.  Fracture  by  contre-coup, 
which  occurs  on  the  side  opposite  the  application  of  the 
violence,  is  very  rare.  Fractures  of  the  skull  are  uncommon 
in  early  youth,  but  they  are  much  more  frequent  in  the  aged. 
Usually  the  entire  thickness  of  the  bone  is  fractured,  but 
either  the  outer  or  the  inner  table  may  be  broken  alone. 
In  complete  fractures  the  inner  table  is  broken  more  exten- 
sively than  is  the  outer  table,  because  the  inner  table  is  the 
more  brittle,  because  the  force  diffuses,  and  also,  as  Agnew 
taught,  because  the  inner  table  is  part  of  a  smaller  curve 
than  is  the  outer  table,  and  violence  forces  bone-elements 


DISEASES  AND   INJURIES    OE   THE   HEAD. 


545 


together  at  the  outer  table,  but  tears  them  asunder  at  the 
inner  table  (Figs.  129,  130). 


Fig.   129. — Section  of  Outer  and   Inner 
Tables,  wiih  two  parallel  lines  (after  Ag- 


FiG.  130.— Greater  Yielding  of  the  Inner 
Table  than  of  the  Outer  after  the  Applica- 
tion of  Violence  (after  Agnew). 


Fractures  of  the  Vault. — A  fracture  of  the  vault  of  the 
skull  may  be  simple  and  undepressed,  or  may  be  depressed, 
compound,  or  comminuted.  A  mere  crack  may  exist  in  a 
bone,  and  if  a  rent  exists  in  the  soft  parts,  a  bit  of  dirt  or  a 
hair  may  be  caught  in  the  crack.  Fractures  of  the  vault  arise 
from  direct  force.  A  fissure  may  escape  recognition,  although 
in  some  cases  percussion  gives  a  "cracked-pot"  sound. 
Any  considerable  depression  can  be  detected.  In  a  simple 
fracture  occasionally  the  cerebro-spinal  fluid  collects  under 
the  scalp  and  forms  a  tumor  which  pulsates  and  becomes 
tense  on  forcible  expiration.  Compound  fractures  can  be 
readily  recognized,  but  Keen  cautions  the  surgeon  not  to 
mistake  a  suture,  a  Wormian  bone,  or  a  tear  in  the  peri- 
cranium for  a  fracture.  A  fissured  fracture  is  marked  by 
a  dark  line  of  blood  which  sponging  will  not  remove. 
Fracture  of  the  inner  table  alone  can  be  suspected  only 
(Keen).  The  prognosis  of  fractures  of  the  vault  depends 
upon  the  extent  of  brain-injury  rather  than  upon  the  extent 
of  bone-injury.  Simple  fractures  unite  by  bone;  compound 
fractures  with  loss  of  bone,  by  fibrous  tissue.  The  dangers 
may  be  immediate  (brain-injury  and  septic  inflammation)  or 
be  elistant  (epilepsy,  insanity,  and  persistent  headache). 

Treatment. — A  simple  fracture  without  depression  and 
35 


546  A   MANUAL    OF  SURGERY. 

without  brain-symptoms  is  treated  expectantly  (by  rest,  quiet, 
low  diet,  purgation,  moderate  elevation  of  and  cold  to  the 
head,  and  arterial  sedatives).  A  simple  fracture  with  mod- 
erate depression  and  without  cerebral  symptoms  is  treated 
expectantly,  and  so  also  is  a  simple  fracture  in  which  symp- 
toms existed  but  are  abating.  Simple  fracture  with  marked 
depression  requires  immediate  trephining,  even  when  brain- 
symptoms  are  absent.  Trephining  in  these  cases  often  pre- 
vents disastrous  consequences,  and  is  known  as  "  preventive 
trephining  "  (Agnew,  Keen,  White,  Horsley,  Macewen).  In 
all  compound  fractures,  shave  and  asepticize  the  entire  scalp, 
enlarge  the  incision,  and  explore  the  bone.  If  a  fissure  exists, 
it  must  be  asepticized,  and  if  a  hair  or  other  foreign  body  is 
found  in  it,  in  order  to  effect  removal  and  secure  asepsis  the 
outer  table  of  the  skull  must  be  cut  away  with  a  chisel,  the 
fissure  being  thus  converted  into  a  broad  groove.  In  a 
compound  fracture  with  much  depression,  trephine,  elevate, 
and  irrigate.  In  any  fracture,  trephine  if  distinct  sym.ptoms 
exist.  In  punctured  wounds  of  the  brain  (punctured  frac- 
tures), ahvays  trephine,  open  the  dura,  and  disinfect  (Keen). 
In  any  case  of  fracture  of  the  vault  where  trephining  has 
been  performed,  do  not  hesitate,  if  it  seems  expedient,  to 
open  the  dura  and  examine  the  brain. 

Fractures  of  the  Base. — A  fracture  of  the  base  of  the 
skull  may  exist  in  only  one  of  the  three  fossse,  in  two  of 
them,  or  it  may  involve  all.  The  middle  fossa  is  oftenest 
involved.  Fracture  of  the  posterior  fossa  is  the  most  fatal. 
These  fractures  may  be  due  to  direct  violence,  to  indirect 
force,  and  to  extension  of  a  fracture  of  the  vault.  Extension 
from  the  vault  is  always  by  the  shortest  route.  Fracture  by 
direct  violence  may  arise  from  the  penetration  of  the  nasal 
roof,  the  orbital  roof,  or  the  pharyngeal  roof  by  a  foreign 
body.  The  posterior  fossa  may  suffer  from  a  fracture  by 
direct  violence  applied  to  the  neck.     Fractures  by  indirect 


DISEASES  AND   INJURIES   OF   THE   HEAD.  547 

force  may  arise  from  blows  upon  the  frontal  bone  (the  orbital 
portion  of  the  frontal  or  the  cribriform  process  of  the  eth- 
moid breaking),  from  falls  upon  the  chin  (the  condyle  of  the 
jaw  breaking  the  middle  fossa),  or  from  falls  upon  the  but- 
tocks, the  knees,  or  the  feet  (fracture  occurring  in  the  poste- 
rior fossa).  The  base  is  very  rarely  broken  by  contre-coup 
(Treves). 

Symptoms. — In  fractures  of  the  base  of  the  skull  blood 
and  cerebro-spinal  fluid  are  apt  to  flow  externally.  In  frac- 
tures of  the  anterior  fossa  blood  may  run  from  the  nose,  its 
source  being  the  laceration  of  the  mucous  membrane  or  the 
vessels  of  the  dura,  the  fracture  being  compound.  Cerebro- 
spinal fluid  only  appears  when  the  mucous  membrane,  the 
dura,  and  the  arachnoid  are  each  lacerated  (Treves).  In 
fractures  of  the  anterior  fossa  blood  is  apt  to  flow  into  the 
orbit,  producing  subconjunctival  ecchymosis,  and  some  blood 
is  often  swallowed  and  vomited.  In  fractures  of  the  middle 
fossa  blood  flows  from  the  ear  through  a  tear  in  the  tympa- 
num, its  source  being  the  vessels  of  the  tympanum,  the 
meningeal  vessels,  or  a  sinus.  Blood  may  flow  through 
the  Eustachian  tube  and  come  from  the  nose,  may  be  spit  up, 
or  may  be  swallowed  and  vomited.  In  many  cases  a  quantity 
of  cerebro-spinal  fluid  flows  from  the  ear,  the  discharge  being 
increased  by  expiratory  effort  and  a  position  which  favors 
gravity.  The  cerebro-spinal  fluid  must  not  be  confused 
with  either  blood-serum  or  liquor  Cotunnii.  The  cerebro- 
spinal fluid  is  always  present  in  large  amount;  the  liquor 
Cotunnii  can  only  be  present  in  minute  amount.  Blood-serum 
is  highly  albuminous  ;  cerebro-spinal  fluid  is  a  serous  fluid 
of  very  low  specific  gravity,  never  shows  more  than  a  trace 
of  albumin,  and  contains  considerable  chloride  of  sodium 
and  in  some  instances  sugar,  which,  when  present,  reacts  to 
Trommer's  and  to  Moore's  test,  but  does  not  reflect  polarized 
light  nor  ferment  with  yeast  (Keetley,  from  Collins).    Treves 


548  A   MANUAL    OF  SURGERY. 

states  ^  that  cerebro-spinal  fluid  cannot  flow  from  the  ear  in 
fractures  of  the  middle  fossa  unless  (i)  the  line  of  fracture 
crosses  the  internal  meatus,  (2)  unless  the  prolongation  of 
the  membranes  into  the  meatus  is  torn,  (3)  unless  a  com- 
munication exists  between  the  internal  ear  and  tympanum, 
and  (4)  unless  the  drum-membrane  is  torn.  Profuse  serous 
discharge  may  flow  from  the  ear  after  an  injury  without  frac- 
ture when  the  drum  is  ruptured,  the  fluid  coming  from  the 
cells  of  the  mastoid.  It  must  be  understood  that  fracture  of 
the  base  may  exist  when  there  is  no  flow  of  blood  or  of 
serous  fluid  (when  the  drum  is  not  lacerated).  A  fracture  of 
the  middle  fossa  is  usually  compound,  made  so,  even  when  the 
drum  is  not  ruptured,  by  the  Eustachian  tube.  In  fracture 
of  the  posterior  fossa  blood  accumulates  beneath  the  deep 
fascia  and  produces  discoloration  in  the  line  of  the  posterior 
auricular  artery  (Battle's  sign),  the  discoloration  first  appear- 
ing near  the  tip  of  the  mastoid.  Fractures  of  the  base  are 
apt  to  be  associated  with  paralysis  of  cranial  nerves.  Optic 
neuritis  often  arises  after  the  first  week.  Dr.  Keen  says  that 
in  fractures  of  the  base  the  temperature  is  subnormal  during 
the  shock,  rises  to  100°  or  101°,  falls  again  to  a  little  below 
normal,  and  remains  normal  or  subnormal  unless  there  be 
inflammation  or  sepsis. 

Treatment. — In  treating  a  fracture  of  the  base  of  the  skull, 
collect  any  serous  discharge  and  analyze  it,  and  disinfect  any 
cavity  involved.  In  fractures  of  the  middle  fossa  with  rup- 
tured drum,  clean  the  ear  mechanically,  wash  it  out  with 
hydrogen  peroxide  and  with  a  stream  of  warm  corrosive- 
sublimate  solution  of  a  strength  of  i  :  2000  (turn  the  head 
toward  the  affected  side,  so  that  the  mercurial  solution  will 
not  run  down  the  Eustachian  tube),  pack  with  iodoform 
gauze,  and  apply  an  antiseptic  dressing.  The  naso-phar\mx 
must  be  cleaned  and  insufflated  with  iodoform.     In  fracture 

1  Applied  Anatomy. 


DISEASES  AND   IXJURIES   OF  THE  HEAD.  549 

of  the  orbit  the  surgeon  must  disinfect,  and  if  the  fracture  is 
punctured,  the  roof  of  the  orbit  must  be  trephined  or  be 
chiseled  to  permit  of  disinfection  and  drainage.  In  fractures 
of  the  middle  and  anterior  fossae  the  naso-pharynx  must  be 
cleaned.  Wash  out  these  cavities  often  with  hot  water,  next 
with  peroxide  of  hydrogen,  and  finally  with  boracic-acid  solu- 
tion. Insufflate  the  naso-pharynx  with  iodoform,  and  pack 
the  nose  with  iodoform  gauze  (Keen,  Dennis).  In  some 
cases  drainage  has  been  obtained  from  the  anterior  fossa  by 
breaking  down  the  cribriform  plate  and  introducing  a  tube 
through  the  nostril  (Allis),  and  from  the  middle  fossa  by 
trephining  above  and  behind  the  external  auditory  meatus. 
In  a  very  extensive  fracture  of  the  base,  besides  use  of  the 
methods  set  forth  above,  the  entire  head  should  be  shaved 
and  a  plaster  cap  be  applied.  Cases  of  fracture  of  the  base 
must  be  put  into  a  quiet  and  darkened  room  and  be  kept 
upon  a  low  diet,  sleep  being  secured  and  the  bowels  and 
bladder  being  attended  to. 

Wounds  of  the  brain  are  produced  by  violence  and  by 
foreign  bodies  (knives,  bullets,  etc.).  Except  when  due  to 
penetration  of  a  fontanelle  in  a  child  or  of  a  parietal  foramen 
in  adults,  wounds  of  the  brain  are  accompanied  by  fracture 
of  the  skull.  These  wounds  are  very  dangerous :  foreign 
bodies  (bone,  hair,  clothing,  etc.)  are  often  lodged  in  the 
brain,  hemorrhage  is  usually  severe,  and  sepsis  is  almost 
inevitable  without  proper  treatment.  These  cases  are  very 
fatal,  though  some  astonishing  recoveries  are  on  record.^ 
The  syniptonis  of  brain-wounds  may  be  slight  and  long- 
deferred  or  may  be  immediate  and  overwhelming ;  they 
depend  upon  the  site  and  extent  of  the  injury.  Localizing 
symptoms  may  exist,  and  encephalitis  with  coma  is  apt  to 
arise.     Abscess  not  unusually  follows.     In  treating  wounds 

^  See  a  most  interesting  and  instructive  paper  by  Dr.  Wm.  J.  Taylor,  read  before 
the  Academy  of  Surgery  of  Philadelphia,  and  reporting  a  number  of  cases. 


550  A   MANUAL    OF  SURGERY. 

of  the  brain,  always  shave  the  entire  scalp  and  examine  the 
weapon  to  see  if  a  piece  were  broken  off.  Asepticize,  enlarge 
the  wound,  trephine,  arrest  bleeding,  elevate  any  depression, 
remove  foreign  bodies,  irrigate  the  wound,  suture  the  dura, 
drain,  and  dress. 

Gunshot  "Wounds  of  the  Head. — A  penetrating  wound  is 
one  in  which  the  bullet  enters  the  head,  but  does  not  emerge  ; 
a  perforatijtg  wound  is  one  in  which  the  bullet  passes 
through  the  head  and  emerges.  The  wound  of  entrance 
is  small ;  the  wound  of  exit  is  large.  At  the  wound  of 
entrance  the  inner  table  is  more  extensively  fractured ;  at 
the  wound  of  exit,  the  outer  table.  The  symptoms  of  gun- 
shot wounds  of  the  head  are  similar  to  those  of  any  other 
brain-wound,  but,  as  a  rule,  are  more  widely  diffused. 

Treatment. — In  treating  gunshot  wounds  of  the  head, 
shave  and  asepticize  the  whole  scalp,  disinfect  the  entire 
track  of  the  ball,  and  arrest  hemorrhage  at  the  wounds  of 
entrance  and  exit,  using  the  rongeur  to  expose  the  bleeding 
points.  The  bullet,  if  retained,  is  to  be  sought  for.  So  place 
the  head  that  the  track  of  the  ball  will  be  vertical,  then  in- 
troduce Fluhrer's  aluminium  probe  and  let  it  find  its  way  by 
gravity.  The  probe  may  find  the  ball  near  the  wound  of 
entrance,  in  which  case  extract  the  ball  with  forceps ;  or  the 
probe  may  find  the  ball  near  the  opposite  side  of  the  head, 
in  which  case  make  a  counter-opening  through  the  bone,  at 
a  point  the  probe  would  touch  if  it  were  pushed  entirely 
across.  Take  a  new  and  clean  rubber  catheter  (No.  9, 
French),  insert  a  stylet,  and  carry  the  catheter  through 
the  wound  (Keen).  Knowing  the  depth  of  the  ball,  it  is 
searched  for  around  the  catheter  tube  as  an  axis,  and  when 
found  it  is  extracted.  After  extraction,  drain  the  wound  by 
means  of  a  tube.  When  a  counter-opening  exists,  drain 
through  and  through.  Girdner's  induction-balance  may  be 
employed  to  locate  a  ball.     If  the  ball  cannot  be  detected, 


DISEASES  AND   INJURIES   OF  THE  HEAD.  55  I 

drain  by  a  tube  carried  to  the  depths  of  the  wound.  After 
dressing,  always  place  the  head  in  a  position  favorable  to 
drainage. 

Fung-US  cerebri  (hernia  of  the  brain)  rarely  contains  true 
brain-substance.  It  is  in  most  instances  a  growth  from  the 
neuroglia.  Hernia  cerebri  cannot  occur  if  the  dura  is  not 
opened  ;  it  is  rare  in  any  case  unless  the  brain  was  damaged, 
and  is  most  frequent  after  septic  wounds.  In  any  brain- 
operation  where  the  dura  is  opened,  suture  it;  or,  if  there  be 
a  great  gap  in  the  dura,  cut  off  a  piece  of  pericranium  from 
the  flap,  turn  its  bone-forming  surface  upward,  and  stitch 
this  membrane  to  the  dura  (Keen).  The  evidence  of  brain- 
hernia  is  a  protruding  mass  which  is  soft,  lobulated,  of  a  dirty- 
white  color,  pulsating,  painless  to  the  touch,  often  bleeding 
and  sometimes  discharging  cerebro-spinal  fluid.  In  treating 
brain-hernia,  employ  antiseptic  dressings.  Skin-grafting 
benefits  some  cases.  Pressure  is  dangerous.  Excision  by 
the  knife  or  cautery  does  no  good.  After  healing,  a  depres- 
sion marks  the  site  of  the  hernia. 

Traumatic  inflammation  of  the  brain  and  its  mem- 
branes is  divided  into  cjicepJialitis  or  cerebritis,  inflammation 
of  the  cerebrum  ;  cercbellitis,  inflammation  of  the  cerebellum; 
ineni7igitis,  inflammation  of  the  meninges;  arachnitis,  inflam- 
mation of  the  arachnoid ;  pachyinefiingitis,  inflammation  of 
the  dura ;  and  leptonieniugitis,  inflammation  of  the  arachnoid 
and  pia. 

Pachy meningitis. — Inflammation  of  the  external  layer  of 
the  dura  is  rare  (pachymeningitis  externa).  It  may  arise 
from  tumor,  caries,  necrosis,  middle-ear  disease,  sunstroke, 
or  traumatism.  Syphilis  is  a  not  unusual  cause.  The  other 
membranes  may  become  involv^ed.  Suppuration  may  arise, 
having  extended  by  contiguity  from  neighboring  parts.  The 
symptoms  of  pachymeningitis  externa  are  uncertain.  They 
resemble  often  those  of  leptomeningitis.    Pressure-symptoms 


552  A    MANUAL    OF  SURGERY. 

may  arise.  Paralysis  may  or  may  not  exist.  If  pus  forms, 
the  ordinary  constitutional  symptoms  of  suppuration  arise 
(high  temperature  and  sweats),  not  the  symptoms  of  abscess 
in  the  brain.  In  a  severe  case  other  membranes  become  in- 
volved. The  treatment  consists  in  removing  the  cause  (cari- 
ous bone,  pus,  middle-ear  disease).  In  pachymeningitis  from 
traumatism,  trephine  to  drain  inflammatory  products ;  in  a 
case  with  localizing  symptoms,  trephine  ;  in  an  ordinary  case, 
without  pus  and  with  no  evidences  of  traumatism,  use  wet 
cups  back  of  the  mastoid  processes,  apply  an  ice-bag  to  the 
head,  and  purge  by  means  of  calomel.  Use  iodide  of  potas- 
sium in  most  cases.  If  sunstroke  is  the  cause,  treat  accord- 
ingly. 

Pachymeningitis  interna  may  extend  from  the  pia.  The 
form  known  as  hcematoma  of  the  dura  mater,  or  pachymenin- 
gitis interna  haemorrhagica,  may  arise  during  infectious  dis- 
eases (typhoid  fever  and  rheumatism),  in  persons  of  the  hem- 
orrhagic diathesis,  in  diseases  causing  atrophy  of  the  brain, 
and  in  chronic  diseases  of  the  heart  and  kidneys.  Among 
the  exciting  causes  are  traumatism,  inflammation  in  adjacent 
parts,  and,  especially,  the  abuse  of  alcohol.  In  this  disease 
blood  is  extravasated  on  the  inner  surface  of  the  dura.  Many 
observers  do  not  class  hemorrhagic  pachymeningitis  as  in- 
flammation, but  regard  the  hemorrhage  as  primary.  The 
symptoms  of  internal  pachymeningitis  are  very  chronic,  are 
not  characteristic,  and  may  be  absent.  They  consist  usually 
of  persistent  headache  and  apoplectiform  attacks  with  con- 
traction of  the  pupil,  slow  pulse,  and  vomiting.  Choked 
disk  is  not  infrequent,  localizing  symptoms  may  be  made 
out,  and  coma- is  apt  to  arise.  The  treatment  is  the  same  as 
that  of  external  pachymeningitis. 

Leptomeningitis  is  a  purulent  inflammation  of  the  soft 
membranes  of  the  brain.  The  pathological  changes  can  be 
noted  in  the  pia  and  in  the  brain-substance.     The  brain  is 


DISEASES  AND   INJURIES   OF   THE  HEAD.  553 

oedematous,  the  pia  purulent,  the  convolutions  are  flattened, 
the  ventricles  are  distended  with  fluid,  and  hemorrhages  occur 
into  the  brain-substance.  Pus  may  be  localized  upon  the 
pia,  but  it  is  usually  diffused  over  one  hemisphere  or  over 
both.  This  disease  may  be  acute  or  be  chronic,  and  a  severe 
case  is  spoken  of  as  encephalitis.  One  form  is  tubercular, 
another  is  syphilitic.  Secondary  leptomeningitis  is  apt  to 
affect  the  convexity;  primary  leptomeningitis  is  apt  to  affect 
the  base  (Hirt). 

The  caiiscs  of  leptomeningitis  are  epidemic  cerebro- 
spinal fever,  tuberculosis,  acute  general  diseases  (pneu- 
monia, typhoid,  erysipelas,  and  rheumatism),  bone  diseases, 
traumatisms,  middle-ear  disease,  syphilis,  and  sunstroke. 
The  tissues  of  the  pia  and  the  cerebro-spinal  fluid  con- 
tain diplococci  identical  with  pneumococci.  Hirt  suggests 
that  these  cocci,  when  no  wound  exists,  effect  an  entrance 
through  the  nose  and  the  ethmoid  foramina.  In  fractures  at 
the  base  the  organisms  enter  by  way  of  the  pharynx  and  the 
Eustachian  tube,  or  the  ear.  The  symptoms  of  acute  lepto- 
meningitis are  violent  headache  persisting  during  delirium, 
rigidity  of  the  neck,  cerebral  vomiting,  a  slow  pulse,  ele- 
vated temperature,  contraction  of  the  pupils,  hyperaesthesia 
of  the  skin  and  muscles,  and  delirium  passing  into  stupor 
and  coma.  Choked  disk,  strabismus,  and  nystagmus  are 
not  unusual.  Convulsions  or  paralyses  may  occur.  Death 
is  the  rule  within  one  week.  The  treatment  is  purgation 
with  calomel ;  bleeding  behind  the  mastoid  processes ;  cold 
to  the  head ;  warm  baths  with  cold  affusions  to  the  head ; 
iodide  of  potassium,  bromide  of  potassium,  or  morphia  for 
vomiting  and  headache.     Some  surgeons  trephine. 

Tuberculous  Meningitis  (Acute  Hydrocephalus ;  Water 
on  the  Brain). — In  a  child  affected  with  meningitis  there  is 
often  a  record  of  a  fall.  Prodromal  symptoms  are  common 
(restlessneas,  irritability,  anorexia,  change  of  character).    The 


554  ^   MANUAL    OF  SURGERY. 

disease  begins  with  a  convulsion  or  with  headache,  fever, 
and  vomiting  (Osier),  the  child  cries  out  from  pain  (the 
hydrocephalic  cry),  and  the  bowels  are  constipated.  The 
pulse  is  rapid,  but  becomes  slow  and  irregular.  The  pupils 
are  contracted,  there  is  muscular  twitching,  and  the  sleep 
is  impaired.  The  temperature  is  about  103°.  In  the  sec- 
ond period  of  the  disease  the  vomiting  ceases,  constipation 
becomes  more  marked,  the  belly  retracts,  headache  is  not 
so  marked,  and  the  patient  lies  in  a  soporose  condition  with 
episodes  of  delirium.  In  this  stage  the  pupils  dilate  and  are 
often  unequal,  the  head  is  retracted,  convulsions  occur  or 
limited  rigidity  is  noted,  the  respiration  is  sighing,  and  if 
a  finger-nail  is  drawn  along  the  skin,  a  red  line  develops 
(the  tdche  cerebrale,  due  to  vaso-motor  paresis).  Squint  and 
consequent  double  vision  are  usual.  In  the  last  stage  coma 
becomes  absolute  and  general  convulsions  or  limited  spasms 
are  apt  to  occur.  Optic  neuritis  exists,  and  the  child  passes 
to  death  along  a  road  identical  with  that  of  typhoid  collapse. 
In  children  the  base  is  usually  involved,  and  the  disease  is 
apt  to  last  from  two  to  four  weeks  ;  in  adults  the  convexity  of 
the  brain  is  usually  involved,  and  death  is  apt  to  occur  in  a 
few  days.  The  treatment  is  like  that  for  traumatic  meningitis. 
Acute  Traumatic  Leptomeningitis  (Acute  Encephalitis). 
— A  day  or  so  after  the  injury  there  appear  severe  general 
headache,  photophobia,  fever  (i02°-i04°),  a  flushing  of  the 
face,  intolerance  of  sound,  contracted  pupils,  a  full  and 
bounding  pulse  (Keen),  constipation,  insomnia,  and  restless- 
ness. A  chill  or  chills  may  occur.  Delirium  soon  sets  in, 
linked  with  muscular  twitching  and  strabismus,  and  followed 
by  stupor,  coma,  rigidity,  paralysis  of  sphincters,  and  a 
typhoid  condition.  Choked  disk  is  sometimes  found,  though 
not  often.  In  this  condition  all  the  membranes  and  the 
brain-substance  suffer.  Acute  encephalitis  should  not  be 
confused  with  uraemia. 


DISEASES  AND   INJURIES   OF   THE   HEAD.  555 

Treatment. — Before  coma  arises,  give  from  five  to  ten 
drops  of  Lugol's  solution  three  times  a  day  (Bartholow) ; 
during  the  stage  of  excitement  ^v^&  aconite  and  opium 
(Bartholow),  and  restrain  convulsions  with  bromide  of 
potassium.  Mercury  does  no  good.  In  acute  traumatic 
encephalitis  interrogate  every  organ.  If  a  wound  ex- 
ists, asepticize  it.  Give  a  calomel  purge  and  keep  the 
bowels  loose ;  shave  the  head  ;  place  the  patient  with  the 
head  raised  in  a  cool,  quiet,  and  darkened  room  ;  use  the 
catheter  whenever  necessary ;  apply  cold  to  the  head  by 
means  of  tubes  or  the  ice-cap ;  in  vigorous  subjects  employ 
venesection ;  leeches  or  wet  cups  over  the  mastoid  and  nape 
of  the  neck  may  be  preferred  to  phlebotomy.  Two  drops 
of  tincture  of  aconite  and  5  drops  of  deodorized  tincture 
of  opium  should  be  given  every  two  or  three  hours  during 
the  stage  of  excitement  (Bartholow),  and  TTLj  of  tincture  of 
gelsemium  may  be  given  with  each  dose.  Large  doses 
of  bromide  are  given  to  restrain  convulsions  and  to  secure 
sleep.  Among  the  hypnotics  that  may  be  used  are  the  hydro- 
bromate  of  hyoscine,  chloral,  and  paraldehyde.  During 
the  stage  of  excitement  apply  mustard  plasters  to  the  fore- 
head and  neck  for  a  short  period  several  times  a  day. 
When  pressure-symptoms  become  evident,  blister  the  nape 
of  the  neck,  the  vertex,  or  the  mastoid  region.  If  great 
depression  comes  on,  give  aromatic  spirits  of  ammonia,  or 
even  wine  (champagne  or  sherry).  The  diet  is  to  consist 
of  milk.  If,  during  coma,  constipation  exists,  give  croton 
oil  and  glycerin.  Never  give  much  opium,  as  it  constipates 
and  adds  to  the  congestion.  It  does  no  good  to  touch  the 
gums  with  mercury :  ptyalism  will  not  check  the  inflamma- 
tion, and  will  enhance  the  danger  (Bartholow).  If  localizing 
symptoms  of  suppuration  arise,  at  once  trephine  and  drain. 
Many  surgeons  are  approaching  the  belief  that  in  this  most 
fatal  disease  trephining  should  be  performed  to  let  out  the 


556  A   MANUAL    OF  SURGERY. 

products  of  inflammation,  thus  relieving  tension,  even  when 
pus  has  not  formed  and  when  distinct  localizing  symptoms 
do  not  exist.  Should  the  patient  recover,  physical  and 
mental  exertion  are  forbidden  for  a  long  time,  and  he  is 
guarded  from  excitement,  worry,  irritation,  constipation,  indi- 
gestion, and  insomnia. 

Chronic  Leptomeningitis  (or  Encephalitis). — The  causes 
of  chronic  leptomeningitis  are  the  same  as  those  of  the 
acute  form.  If  traumatism  is  the  cause,  the  inflammation 
arises  at  a  later  period  than  it  would  in  acute  encephalitis. 
The  symptoms  of  concussion  follow  a  head-injury.  Days, 
or  even  weeks,  after  the  accident,  a  series  of  symptoms 
occur,  namely:  localized  pain  at  the  seat  of  injury,  often 
accentuated  by  tapping ;  listlessness ;  irritability ;  apathy 
regarding  business  affairs  and  home  obligations,  or  profound 
depression  and  hypochondria  with  inability  to  attend  to 
business.  Choked  disk  exists.  Soon  acute  encephalitis 
arises,  with  or  without  a  chill.  The  treatment  of  this  disease 
is  the  same  as  that  for  acute  encephalitis.  Always  operate 
if  localizing  symptoms  are  found.  Intense  local  pain  justi- 
fies trephining. 

Abscess  of  the  brain  is  a  localized  collection  of  pus.  The 
causes  are  suppurative  otitis  media  (in  half  of  all  the  cases), 
fracture  of  the  skull,  concussion  of  the  brain,  and  general 
septic  diseases.  A  tubercular  mass  may  caseate  (tubercular 
abscess).  The  abscess  may  be  between  the  dura  and  skull 
(extradural),  between  the  dura  and  brain  (subdural),  or  in 
the  brain-substance  (cerebral  or  cerebellar).  A  traumatic 
abscess  is  generally  beneath  the  injured  area,  but  it  may  be 
on  the  opposite  side. 

Symptoms  of  Abscess  of  the  Cerebral  Substance. — The 
symptoms  due  to  pus-formation  are  as  follows :  There 
may  be  an  initial  rise  of  temperature,  but  (except  in 
extradural    abscess)    the    temperature    becomes    normal    or 


DISEASES  AND   INJURIES   OF   THE   HEAD.  557 

subnormal.  Toward  the  end  of  the  case  the  temperature 
may  rise  and  the  fever  is  Hnked  with  deHrium.  The  local 
temperature  over  the  abscess  may  be  elevated.  A  chill 
may  or  may  not  occur.  Anorexia  and  vomiting  are  pres- 
ent. .Urinary  chlorides  are  diminished  and  the  phosphates 
are  increased  (Somerville).  Symptoms  due  to  pressure  are 
— headache  (which  at  first  is  general,  then  local,  and  grows 
worse  later  in  the  case,  when  fever  arises  and  exists  even 
in  delirium :  this  fact  distinguishes  it  from  the  headache 
of  fever,  which  ceases  in  delirium);  pulse  is  very  slow; 
respiration  tends  to  the  Cheyne-Stokes  type ;  stupor  passes 
into  coma ;  paralysis  of  the  sphincters  takes  place ;  con- 
vulsions are  common ;  sensation  is  rarely  impaired ;  and 
paralysis  of  the  basal  nerves  may  occur  (third  and  sixth 
especially).  The  pupil  on  the  same  side  as  the  abscess  is 
dilated  and  fixed.  Choked  disk  is  not  invariably  found ; 
if  it  is  unilateral,  it  is  on  the  same  side  as  the  abscess ;  if 
it  is  bilateral,  it  is  more  marked  on  the  same  side  as  the 
abscess.  In  cerebellar  abscess  there  are  vertisfo,  vomitine. 
occipital  headache,  rigidity  of  the  post-cervical  muscles,  and 
inco-ordination.  Choked  disk  is  often  absent.  Localizingr 
symptoms  depend  upon  the  centre  which  is  irritated  or 
destroyed. 

Meimigitis  arises  soon  after  an  accident ;  an  abscess,  more 
than  a  week,  often  many  weeks,  after  an  accident.  Menin- 
gitis presents  high  temperature  and  the  general  symptoms 
before  outlined.  Mastoid  disease  may  occasion  cerebral 
symptoms  without  abscess,  or  it  may  cause  abscess.  In 
siinis  thrombosis  there  is  septic  temperature,  the  veins  of  the 
face  and  neck  are  enlarged,  and  a  clot  can  usually  be  felt 
in  the  jugular.  A  tumor  grows  slowly,  usually  presents 
almost  from  the  start  distant  localizing  symptoms,  and 
double  choked  disk  is  frequently  present.  In  tumor  the 
temperature  is  apt  to  be  normal. 


558  A   MANUAL    OF  SURGERY. 

Trcatnioit. — If  localizing  symptoms  exist,  trephine  the 
skull  at  once,  and,  if  no  pus  is  found  between  the  bone  and 
dura,  open  the  membrane.  When  the  dura  is  opened,  if 
the  abscess  is  subdural,  pus  will  be  evacuated ;  if  the  abscess 
is  in  the  brain-substance,  the  brain  will  bulge  very  much  and 
will  not  be  seen  to  pulsate.  A  grooved  director  is  plunged 
into  the  brain,  in  the  direction  of  the  abscess,  for  two  or  two 
and  a  half  inches  (Keen).  If  pus  is  not  found,  withdraw  the 
director  and  introduce  it  at  another  point.  When  pus  is 
found,  incise  the  brain  with  a  knife,  enlarge  the  opening  by 
expanding  the  blades  of  a  pair  of  forceps,  scrape  away  the 
granulation  tissue  lining  the  abscess-cavity,  irrigate  with 
boiled  water,  and  introduce  a  rubber  drainage-tube ;  stitch 
the  dura,  bring  the  tube  out  through  a  button-hole  in  the 
scalp,  and  after  the  first  two  days  pull  the  tube  out  a  little 
every  day  and  cut  off  a  piece.  If  the  first  trephining  does 
not  find  pus,  trephine  again  at  another  point.  In  cerebellar 
abscess,  make  a  flap  with  the  base  up,  and  trephine  or  gouge 
away  the  bone  just  below  a  line  drawn  from  the  inion  to  the 
external  auditory  meatus  (to  avoid  the  lateral  sinus). 
Puncture  the  brain  as  for  cerebral  abscess. 

Brain  Disease  from  Suppurative  Bar  Disease. — Chronic 
disease  of  the  middle  ear  is  apt  to  destroy  the  bone  between 
the  tympanum  and  the  middle  fossa  of  the  skull,  and  thus 
produce  meningitis,  thrombosis  of  the  petrosal  or  lateral 
sinuses,  abscess  of  the  temporo-sphenoidal  lobe  or  of  the 
cerebellum,  or  extradural  abscess.  This  teaches  the  surgeon 
that  chronic  ear  disease  should  never  be  neglected,  but 
should  receive  the  closest  attention  of  the  specialist  if  pos- 
sible. In  ordinary  cases  cleanliness  and  antisepsis  are 
sufficient,  the  ear  being  syringed  every  day  with  a  warm 
2  per  cent,  solution  of  common  salt.  If  only  a  small  drum- 
perforation  exists,  lo  drops  of  pure  alcohol  or  of  corrosive- 
sublimate  solution  (i  :  5000)  are  dropped  into  the  ear,  but 


DISEASES  AND   INJURIES   OF   THE   HEAD.  559 

if  a  large  drum-perforation  exists,  boric  acid  and  iodoform 
(7  to  i)  are  insufflated.  Never  inject  alum.  A  strong  silver 
solution  is  not  safe ;  if  it  is  used,  wash  the  ear  out  afterward 
with  warm  salt  water.  If  granulations  or  polypi  exist,  they 
must  be  removed  (Burnett).  Some  cases  require  the  removal 
of  the  drum-membrane  and  the  ossicles  of  the  ear.  If  head- 
ache, vomiting,  and  mastoid  tenderness  exist,  open  the  mas- 
toid at  once  (see  Operations)  to  prevent  abscess  of  the  brain. 
Cerebral  abscess  from  ear  disease  is  almost  always  in 
the  temporo-sphenoidal  lobe.  The  syniptoms  are — sudden 
disappearance  of  the  ear-discharge ;  a  transient  rise  of  tem- 
perature followed  by  a  subnormal  temperature ;  vomiting ; 
mastoid,  frontal,  and  temporal  pain ;  the  mind  is  dull,  and 
stupor  arises  which  passes  into  coma ;  the  bowels  are  con- 
stipated ;  choked  disk  may  be  present ;  and  convulsions  or 
spasms  or  paralyses  may  exist.  Trephine  and  clean  out 
the  mastoid  antrum,  and  asepticize  (see  Operations  upon  the 
Skull  and  Braiii).  Trephine  at  Barker's  point,  one  and  one- 
fourth  inches  behind,  and  the  same  distance  above,  the 
middle  of  the  external  auditory  meatus.  If  pus  is  not 
found,  open   the  cerebellum. 

Extradural  Abscess. — The  eye  symptoms  and  pain  are 
the  same  in  this  as  in  cerebral  or  subdural  abscess,  but  the 
temperature  is  different,  rising  to  103°  or  104°.  There  is 
often  considerable  tenderness  above  and  behind  the  mastoid. 
Trephine  and  clean  out  the  mastoid ;  follow  up  a  sinus  to 
the  abscess,  rongeur  away  the  bone,  avoiding  the  lateral 
sinus,   curette,  irrigate,  and  drain. 

Infective  Sinus  Thrombosis  (a  form  of  Pyaemia). — The 
symptoms  of  this  disease  present  a  history  of  chronic  ear 
disease ;  general  headache  and  pain  over  the  sinus  arise ; 
violent  rigors  occur;  and  the  temperature  rises  and  fluctu- 
ates greatly.  Tenderness  and  marked  oedema  are  detected 
over  the  mastoid.     A  clot  may  be  felt  in  the  neck,  in  the 


560  A   MANUAL    OF  SURGERY. 

internal  jugular  vein.  The  veins  of  the  face  swell.  Choked 
disk  usually  exists.  The  mind  is  generally  clear,  at  least  for 
a  time. 

Treatment. — Infective  sinus  thrombosis  is  treated  as  fol- 
lows :  Open  and  clean  out  the  mastoid,  and  expose  the  sinus  ; 
irrigate ;  open  the  sinus,  which,  if  full  of  clot,  will  not  bleed  ; 
introduce  a  small  spoon  in  the  sinus,  carry  it  toward  the 
torcular  Herophili,  and  scrape  away  the  clot  until  blood 
flows.  When  bleeding  begins,  arrest  it  by  packing  the  side 
of  the  sinus  toward  the  occiput.  Incise  the  neck,  expose 
the  internal  jugular  vein,  ligate  the  vein  below  the  clot, 
divide  the  vein  above  the  ligature,  and  wash  out  the  clot 
by  running  a  stream  of  corrosive  sublimate  in  at  the  lateral 
sinus  and  out  at  the  cut  jugular.  Suture  the  neck- wound, 
drain  the  mastoid,  and  apply  sutures  in  the  soft  parts. 

Intracranial  tumors  may  be  true  neoplasms,  may  be  of 
parasitic  origin,  may  result  from  injury,  or  may  be  tubercular 
or  syphilitic.  Among  these  tumors  are  papillomata,  gliomata, 
sarcomata,  fibromata,  psammomata,  myxomata,  osteomata, 
etc.  (see  Tinnors).  Cysts  sometimes  occur.  The  symptoms 
are  diffuse  and  local,  and  are  similar  in  many  particulars  to 
the  symptoms  of  some  other  lesions.  Among  the  symptoms 
are  headache,  pain  on  percussion,  vertigo,  vomiting,  epileptic 
convulsions,  double  choked  disk,  partial  or  complete  blind- 
ness, paralyses  of  eye-muscles,  paralysis  of  face  or  of  limb, 
anaesthesia  and  aphasia,  word-deafness,  word-blindness,  agra- 
phia, inco-ordination,  and  mental  disturbances.  The  situation 
of  a  tumor  is  fixed  from  localizing  symptoms,  their  mode  of 
onset  and  manner  of  combination.  The  nature  of  the  tumor, 
its  size,  its  depth,  and  whether  it  is  single  or  other  tumors 
exist,  is,  if  possible,  determined. 

Treatment. — If  the  tumor  is  located  in  an  accessible  region 
and  operation  is  indicated,  trephine  the  skull,  enlarge  the 
opening  with  the  rongeur,  open  the  dura,  and  turn  out  the 


DISEASES  AND   IXJURIES   OF   THE   HEAD.  56 1 

tumor  by  means  of  the  finger,  or,  if  this  is  impossible,  by 
using  an  AUis  dissector,  a  knife,  the  scissors,  or  a  sharp 
spoon.  If  the  tumor  is  beneath  the  cortex,  incise  the  brain 
with  a  knife.  Arrest  bleeding,  stitch  the  dura,  drain,  and 
close,  the  wound. 

Operative  Treatment  of  Epilepsy. — When  epilepsy  has 
followed  traumatism  and  a  scar  exists  upon  the  scalp,  excise 
the  scar,  especially  if  it  is  tender  or  is  the  seat  of  an  aura. 
If,  on  lifting  the  scalp,  a  depression  of  bone  or  a  disease  of 
the  bone  is  manifest,  trephine  for  exploration,  even  over  a 
silent  area.  Remember  that  epilepsy,  as  shown  by  Sachs, 
may  follow  a  long-forgotten  injur>\  Where  the  injury  is 
over  a  known  centre,  trephine.  This  operation  is  especially 
indicated  when  the  convulsions  begin  in  the  muscles  of  this 
centre,  in  which  case  remove  the  centre  after  trephining. 
Remove  all  sources  of  peripheral  irritation  (Briggs  reported 
a  case  of  epilepsy  in  which  there  was  distinct  skull-depres- 
sion and  necrosis  of  the  tibia,  but  the  cure  of  the  necrosis 
stopped  the  fits).  Trephining  in  epilepsy  may  disclose  a 
cyst,  a  dural  scar,  a  brain-scar,  a  depressed  portion  of  bone, 
or  eburnation  of  bone  from  osteitis  (Keen).  In  exploratory 
operations  for  epilepsy,  ahvays  open  the  dura.  If  epilepsy 
arises  notwithstanding  a  primary  trephining,  open  the  flap, 
round  the  bony  edges  with  a  rongeur,  and  cut  out  the  scar.^ 

These  operations  often  seem  to  cure,  but  sometimes  so 
does  any  operation.  Dr.  White  records  ^  ninety  trephinings 
in  which,  though  nothing  was  found,  great  relief  followed, 
and  two  cases  were  apparently  cured  ;  he  mentions  benefit 
or  apparent  cure  following  tracheotomy,  ligation  of  the 
carotid,  incision  of  the  scalp,  etc.  The  fact  seems  to  be  that 
any  operation,  by  means  of  nervous  shock,  may  interrupt 

^  The  author,  in  Hare's   Sy stein  of  Practical  Therapeutics. 
2  "  The  Supposed  Curative  Effects  of  Operations  per  se"  Annals  of  Surgery, 
August  and  September,  1891. 
36 


562  A   MANUAL    OF  SURGERY. 

the  epileptic  habit ;  but  in  ordinary  operations  the  fits  tend 
to  recur,  and  soon  reach  their  old  standard  of  frequency. 
In  the  special  brain-operations  with  excision  of  obvious 
lesions  or  discharging  centres,  the  fits  often  recur,  but  they 
will  rarely  reach  the  old  standard  of  frequency,  and  will 
be  more  amenable  to  medical  treatment  In  non-traumatic 
epilepsy  the  fits  are  to  be  studied  by  a  competent  observer 
(Keen),  and,  if  focal  epilepsy  or  Jacksonian  epilepsy  exists, 
trephining  is  to  be  performed  over  the  diseased  centre  and 
the  explosive  focus  is  to  be  located  by  an  electric  current 
and  removed.  In  favor  of  this  procedure  is  the  high  author- 
ity of  Keen,  Horsley,  and  Macewen,  This  operation  causes 
paralysis,  but  the  paralysis  is  rarely  permanent  except,  per- 
haps, to  the  finer  movements. 

In  non-traumatic  chronic  epilepsy  without  localizing  symp- 
toms trephining  is  not  justifiable  unless  persistent  headache 
calls  for  it  as  a  means  of  relief  from  intracranial  pressure. 
After  trephining  for  epilepsy  five  years  should  elapse  without 
a  convulsion  before  cure  is  reasonably  assured,  and  if  con- 
vulsions arise,  they  must  at  once  be  met  by  medical  treat- 
ment. A  man  having  once  had  a  convulsion  may  at  any 
time  have  more ;  hence  he  should  always  be  watched.  It  is 
not  unusual  for  a  few  convulsions  to  occur  soon  after  an 
operation,  and  then  to  cease.  These  early  fits  result  from 
habit.  Among  the  operative  procedures  suggested  for  the 
treatment  of  epilepsy  may  be  mentioned  circumcision,  clito- 
ridectomy,  ocular  tenotomy,  ligation  of  the  vertebral  arteries, 
removal  of  the  cervical  ganglia  of  the  sympathetic  (Alex- 
ander), and  the  actual  cautery  to  the  head  (Fere). 

Operations  on  the  Skull  and  Brain. — Trephining  (for 
a  fractured  skull). — Shave  the  scalp,  wash  it  with  ethereal 
soap,  then  with  ether,  scrub  with  a  brush  wet  with  corro- 
sive-sublimate solution  (i  :  looo),  and  wrap  up  the  scalp  in 
wet  corrosive-sublimate  gauze  (i  :  2000).     The  instruments 


DISEASES  AND   INJURIES   OF   THE   HEAD.  563 

required  are  a  scalpel,  an  Allis  dissector,  haemostatic,  dissect- 
ing, and  toothed  forceps,  trephines  of  several  sizes,  a  perios- 
teum-elevator, a  Hey  saw,  rongeur  forceps,  a  bone-elevator, 
a  dural  separator,  a  tenaculum,  small  curved  Hagedorn 
needles,  and  a  needle-holder.  Provide  a  sand  pillow.  The 
patient  lies  upon  his  back,  the  shoulders  are  a  little  raised, 
the  sand  pillow  is  placed  under  the  neck,  and  his  head  is 
turned  away  from  the  side  to  be  operated  upon.  The  posi- 
tion of  the  surgeon  is  such  that  the  patient's  head  is  a  little 
to  his  left.  A  large  semilunar  incision  is  made  with  the  base 
down,  which  incision  goes  through  the  periosteum,  and  the 
flap  is  lifted.  The  bleeding  vessels  of  the  flap  are  caught 
with  forceps.  The  pin  of  the  trephine  is  projected  beyond 
the  crown  and  is  set  upon  sound  bone,  the  crown  overhang- 
ing the  line  or  edge  of  the  fracture.  A  gutter  is  cut  in  the 
bone,  the  pin  is  withdrawn,  and  the  trephining  is  completed. 
In  going  through  the  diploe  bleeding  is  copious  and  the 
inner  table  feels  very  dense.  Stop  from  time  to  time,  clean 
out  the  gutter  with  the  dissector,  and  try  the  bone  with  an 
elevator  to  see  if  it  is  loose.  When  the  fragment  is  loose 
enough,  pry  it  out  and  hand  it  to  an  assistant,  who  places  it 
at  once  in  a  bowl  of  solution  of  corrosive  sublimate  (i  :  2000) 
kept  warm  by  standing  in  a  basin  of  water  at  105°,  or  who 
puts  it  in  warm  carbolized  towels  or  in  warm  normal  salt- 
solution.  The  edges  of  the  opening  are  rounded  with  a 
rongeur  and  the  bone  is  elevated.  Sometimes  it  may  be 
necessary  to  remove  splinters  and  fragments  of  bone.  The 
dura  is  examined  to  see  if  injury  exists,  hemorrhage  is 
arrested,  the  wound  is  cleansed,  the  button  of  bone  is  re- 
introduced, or  some  chips  are  cut  from  it  and  scattered  upon 
the  dura.  The  scalp  is  sutured  and  horse-hair  drainage  is 
employed  for  a  day  or  two.  Sterilized  gauze  dressings  are 
put  on,  a  rubber  dam  is  laid  over  them,  and  a  gauze  bandage 
wet  with  bichloride-of-mercury  solution  is  applied. 


564  A   MANUAL    OF  SURGERY. 

Technique  of  Brain-operations  (after  Horsley  and  Keen). 
— Always  shave  the  scalp,  and  always  antisepticize  it.  In 
localizations,  mark  out  the  fissure  upon  the  scalp  with  an 
aniline  pencil  or  with  iodine.  Have  the  patient  semi-recum- 
bent. Mark  three  points  upon  the  bone  with  the  centre-pin 
of  the  trephine  before  incising  the  scalp  (both  ends  of  the 
Rolandic  fissure  and  the  point  at  which  the  trephine  will  be 
applied).  Make  a  semilunar  flap  three  inches  in  diameter, 
with  the  base  below.  Control  bleeding  in  the  flap  by  forceps 
pressure.  The  one  and  a  half  inch  trephine  is  used,  but,  if  a 
smaller  trephine  is  employed,  the  opening  must  be  enlarged 
with  a  rongeur.  Before  enlarging  the  opening,  separate  the 
dura  from  the  bone  by  a  dural  separator.  As  a  rule,  open 
the  dura  and  examine  the  brain.  The  dura  is  lifted  by  rat- 
toothed  forceps  and  is  opened  with  scissors  along  a  line  a 
quarter  of  an  inch  from  the  bone-edge.  Hemorrhage  is 
arrested  by  pressure  and  hot  water  or  by  passing  a  curved 
needle  threaded  with  catgut  around  any  bleeding  vessel.  In 
some  cases  packing  must  be  left  in  or  forceps  must  be  kept  on. 
In  packing,  never  use  more  than  one  piece  of  gauze,  so  as  to 
avoid  leaving  in  a  forgotten  piece.  Upon  opening  the  dura, 
cerebro-spinal  fluid  flows  out,  the  stream  being  increased  with 
each  expiration.  Absence  of  pulsation  of  the  brain  points 
to  tumor,  and  a  livid  color  indicates  subcortical  growth. 
An  old  laceration  is  brownish.  If  the  brain  bulges  through 
the  opening,  it  means  increased  pressure  (tumor,  abscess, 
effusion  into  the  ventricles,  etc.).  After  opening  the  dura, 
employ  no  antiseptics  except  boiled  water,  especially  when 
the  surgeon  intends  using  electricity  to  locate  a  centre.  Re- 
move any  abnormal  brain-tissue  which  is  found.  In  electri- 
fying the  brain,  faradism  is  employed  of  a  strength  about 
sufficient  to  move  the  thenar  muscles  when  applied  to  them. 
After  an  aseptic  cerebral  operation,  as  a  rule,  do  not  drain. 
In  many  cases  replace  the  bone,  but  not  when  the  bone  is 


DISEASES  AND   INJURIES   OF   THE   HEAD.  565 

diseased,  is  infected,  or  is  very  compact,  or  if  it  is  desired  to 
alter  pressure.  The  dura  is  sutured  by  a  continuous  catgut 
suture  (Fig.  131);  the  scalp  is  sutured  by  interrupted  silk- 
worm  gut  (Fig.    132). 


h;  "--.  ^  \ 


Fig.   131.— Continuous  Suture.  Fig.  132.— Interrupted  Suture. 

Operation  for  Mastoid  Suppuration. — The  instruments 
required  in  this  operation  are  a  scalpel,  a  gouge,  a  chisel,  a 
mallet,  curettes,  a  probe,  a  dissector,  dissecting  and  haemo- 
static forceps,  and  needles.  Provide  a  sand-bag  to  place 
under  the  neck.  An  incision  is  made  one-quarter  of  an  inch 
posterior  to  the  auricle  and  down  to  the  bone.  The  bone  is 
bared  and  examined  especially  at  a  point  in  the  line  of  the 
incision  which  is  on  a  level  with  the  roof  of  the  meatus. 
The  bone  will  usually  be  found  softened.  Gouge  it  away 
and  thus  open  the  mastoid  antrum.  This  bone-opening  is 
within  the  limits  of  Macewen's  suprameatal  triangle,  a  space 
bounded  by  the  posterior  root  of  the  zygoma,  the  posterior 
bony  wall  of  the  meatus,  and  a  line  joining  the  two.  If,  in 
the  adult,  pus  is  not  found,  gouge  downward  and  backward, 
but  with  great  care,  so  as  to  avoid  the  lateral  sinus.  After 
evacuating  the  pus,  scrape  out  the  cavities  with  the  curette, 
enlarge  the  opening  between  the  mastoid  and  the  middle  ear 
with  the  gouge,  turn  the  head  toward  the  side  operated  upon, 
and  irrigate  the  mastoid  with  corrosive-sublimate  solution 
(i  :  2000) ;  dust  in  iodoform,  pack  with  iodoform  gauze  for 
a  few  days,  and  then  introduce  a  silver  drainage-tube.  Treat 
the  causative  ear  disease. 

If   mastoid   suppuration    has    established   abscess   in    the 


566  A   MANUAL    OF  SURGERY. 

tcmporo-sphe7toidal  lobe,  trephine  one  and  a  quarter  inches 
behind  and  one  and  a  quarter  inches  above  the  middle  of 
the  external  meatus  (Barker's  point),  and  search  for  pus  as 
directed  on  p.  559.  If  abscess  of  the  ccrebclhun  exists,  tre- 
phine below  the  line  of  the  lateral  sinus — that  is,  below  a 
line  running  from  the  inion  to  a  point  on  a  horizontal  line 
from  the  roof  of  the  meatus,  one  inch  posterior  to  the 
middle  of  the  meatus.  If  infective  siiiiis  thrombosis  exists, 
break  into  the  lateral  sinus  through  the  mastoid  opening  and 
proceed  as  directed  on  p.  560. 


XXIII.  SURGERY  OF  THE  SPINE. 

Congenital  Deformities. — Spina  bifida^  or  hydrorrha- 
chitis,  is  a  congenital  cystic  tumor  due  to  vertebral  deficiency, 
permitting  protrusion  of  the  contents  of  the  spinal  canal  in 
the  median  line.  The  laminae  or  spines  of  one  vertebra  or 
of  several  vertebrae  may  be  deficient,  most  frequently  in  the 
lumbo-sacral  region.  Meningocele  is  a  protrusion  of  dura 
mater  and  arachnoid,  the  sac  containing  cerebro-spinal  fluid, 
but  no  nerves  and  no  cord-substance.  Meningo-niyelocele 
(the  commonest  form)  is  a  protrusion  of  dura  mater  and 
arachnoid,  the  sac  containing  cerebro-spinal  fluid,  nerves, 
and  cord-substance.  The  cord  may  spread  out  upon  the  sac- 
wall  or  it  may  pass  through  the  sac  and  re-enter  the  canal. 
Syringo-niyeloccle  is  great  distention  of  the  central  canal, 
the  sac-wall  being  formed  of  the  thinned  cord.  A  hydror- 
rhachis  varies  in  size  from  that  of  a  walnut  to  that  of  a 
child's  head ;  it  grows  rapidly  during  the  early  weeks  of 
life  ;  it  is  usually  sessile,  but  may  present  where  it  joins 
the  body  a  definite  constriction,  or  even  a  pedicle  ;  the  base 
of  the  sac  is  covered  with  healthy  skin,  and  the  fundus  is 
covered  only  by  thin  epidermis  or  by  the  spinal  membranes 
themselves.     Pressure  upon  the  tumor  is  found  to  diminish 


SURGERY  OF   THE   SP/.VE.  567 

its  size  and  to  increase  the  tension  of  the  anterior  fontanelle, 
and  possibh'  to  cause  convulsions  or  stupor.  The  cyst  is 
translucent,  and  the  margins  of  the  bony  aperture  are  dis- 
tinct. Crying,  coughing,  or  pressure  upon  the  anterior 
fontanelle  makes  the  tumor  more  tense.  Spina  bifida  is 
apt  to  be  associated  with  club-foot,  with  hydrocephalus, 
and  with  rectal  or  vesical  paralysis.  Spina  bifida  usually 
causes  death.  A  few  meningoceles  and  a  very  few  meningo 
myeloceles  undergo  spontaneous  cure  by  the  shrinking  of 
the  sac.  Syringo-myelocele  is  invariably  fatal.  The  cause 
of  death  may  be  rupture  of  the  sac  or  marasmus. 

Treatment. — Very  small  protrusions  which  grow  slowly 
and  are  covered  with  sound  skin  may  be  treated  by  the  use 
of  a  compress  and  bandage,  by  an  elastic  bandage,  or  by 
applications  of  contractile  collodion.  Some  surgeons  tap 
and  drain  the  sac.  Injection  is  used  by  man\\  The  sac 
being  cleaned,  the  child  is  placed  on  its  side  and  a  little 
chloroform  is  given.  A  fine  trocar  is  plunged  obliquely  in 
at  the  side  through  sound  skin,  little  or  no  fluid  being 
drawn  off,  and  3j  of  Morton's  fluid  is  injected  (iodine,  gr.  x ; 
iodide  of  potassium,  gr.  xxx  ;  glycerin,  5J).  The  trocar  is 
withdrawn  and  the  puncture  is  sealed  with  a  bit  of  gauze 
and  iodoform  collodion.  The  child  is  put  to  bed.  If  the 
injection  proves  successful,  the  sac  shrinks ;  if  the  injection 
fails,  it  may  be  repeated  at  intervals  of  from  seven  to  ten 
days  (Jacobson,  White).  Many  surgeons  prefer  excision  of 
the  sac.     Bayer  treats  it  as  he  would  a  hernia. 

Tumors  of  the  Spine. — Among  congenital  tumors  are 
lipomata  and  cysts  (dermoid,  congenital,  sacral,  and  fcetal). 
Tubercle,  gumma,  psammoma,  and  fibroma  may  arise  from 
the  cord  or  its  membranes.  Glioma  is  the  most  usual 
growth.  Primar\^  sarcoma  is  rare.  Angeioma  may  occur. 
Carcinoma  is  never  primary.  A  tumor  rarely  produces  obvi- 
ous symptoms  until  it  is  as  large  as  a  hazel-nut. 


568  A   MANUAL    OF  SURGERY. 

Symptoms  and  Trcatmoit. — Pain,  stiffness  of  the  back, 
areas  of  anaesthesia,  and  progressively  advancing  motor 
paralysis  are  symptoms  of  spinal  tumors.  A  tumor  may 
produce  the  symptoms  of  compression-myelitis,  locomotor 
ataxia,  or  myelitis.  In  glioma  there  are  apt  to  be  loss  of 
ability  to  recognize  variations  of  temperature  (or  even  to 
distinguish  between  heat  and  cold),  loss  of  the  sense  of 
pain,  and  paresis  and  atrophy  of  muscles.  Contractures 
or  paraplegia  may  arise.  The  location  of  the  tumor  can  be 
inferred  by  a  study  of  the  territory  of  paralysis  and  the 
zone  of  sensory  disturbance.  The  tumor  is  always  somewhat 
above  the  upper  limit  of  anaesthesia.  In  many  cases  the 
diagnosis  is  impossible.  Gradually  increasing  painful  para- 
plegia, with  pain  in  the  back  or  with  sensory  paralysis  after 
a  time  appearing  and  ascending  from  the  feet  toward  the 
trunk,  points  to  tumor  as  a  cause.  .The  reflexes  are  at  first 
increased,  but  are  finally  lost  from  below  upward.  Spasms 
may  develop,  and  spinal  curvature  may  arise.  Growths  out- 
side the  membranes  produce  more  pain  and  spasm ;  growths 
within  the  membranes  produce  more  motor  paralysis  and 
anaesthesia.  If  syphilis  is  suspected,  give  the  patient  a  heroic 
course  of  iodide  of  potassium.  In  a  focal  lesion  not  due  to 
dissemination  of  a  known  malignant  growth,  perform  the 
operation  of  laminectomy  to  permit  of  exploration  and  pos- 
sibly of  removal. 

Spinal  Curvatures. — There  are  four  chief  forms  of  spinal 
curvature:  (i)  lateral  curvature  (the  scoliosis  of  the  older 
surgeons);  (2)  posterior  curvature  (the  excurvation,  gib- 
bosity, or  kyphosis  of  the  older  surgeons);  (3)  anterior 
curvature  (the  lordosis  of  the  older  surgeons) ;  and  (4) 
angular  curvature  (from  spinal  caries).  The  normal  spine 
has  four  curves  :  the  cervical  curve,  the  convexity  of  which 
is  forward ;  the  dorsal  curve,  the  concavity  of  which  is  for- 
ward;   the  lumbar  curve,  which  is  convex  anteriorly;   and 


SURGERY  OF   THE   SPINE.  569 

the  pelvic  curve,  which  is  concave  anteriorly.  The  dorsal 
and  the  pelvic  curves,  which  are  primary,  are  due  to  the 
formation  of  the  cavities  of  the  chest  and  pelvis,  and  depend 
upon  the  shape  of  the  bones  (Treves).  The  cervical  and 
lumbar  curv^es,  which  are  compensatory,  depend  upon  the 
shape  of  the  intervertebral  disks,  and  only  appear  after  birth 
when  the  erect  position  is  assumed. 

Lateral  curvature  (scoliosis)  is  a  lateral  deviation  of  the 
spinal  column,  often  accompanied  with  rotation  of  the 
vertebrae  and  associated  with  increase  or  with  diminution 
of  the  normal  curves.  Lateral  curvature  is  predisposed  to 
by  weak  muscles  and  ligaments,  by  the  habitual  assumption 
of  strained  and  unnatural  attitudes,  by  unequal  length  of  the 
legs,  and  by  paralysis  of  one  leg.  This  distortion,  which  is 
commonest  in  girls,  is  apt  to  arise  at  the  age  of  puberty 
(it  is  usually  corrected  in  boys  by  outdoor  exercise).  The 
bones  are  soft  and  the  muscles  are  weak,  and  this  con- 
dition is  often  hereditary.  Rickets  is  very  commonly  asso- 
ciated with  lateral  curvature.  Anv  condition  of  ill-health 
weakens  the  muscles  ;  hence  lateral  curvature  may  arise  after 
an  acute  sickness  or  in  a  person  who  outgrows  his  strength. 
An  empyema  with  adhesions,  by  pulling  on  the  chest-wall, 
may  produce  a  curvature  the  concavity  of  which  is  toward 
the  diseased  side. 

The  weak  muscles  cease  to  sustain  the  spinal  column,  and 
the  ligaments  stretch,  relax,  or  lengthen.  The  commonest 
curve  is  toward  the  right  in  the  dorsal  region  (because  most 
people  use  the  right  hand  more  than  the  left).  As  soon  as 
a  dorsal  curve  to  the  right  arises,  a  compensatory  lumbar 
curve  (Fig.  133)  takes  place  to  the  left,  thus  enabling  the 
patient  still  to  sit  or  to  stand  erect.  In  almost  all  cases  the 
vertebrae  soon  rotate,  the  bodies  turning  to  the  convexity 
and  the  spines  turning  to  the  concavity  of  the  curve ;  hence 
the  transverse  processes  toward  the  convexity  project.     The 


570  A   MANUAL    OF  SURGERY. 

ribs  follow  the  spinal  rotation ;  the  shoulder  is  elevated  on 
the  side  of  the  convexity,  and  the  hip  on  the  same  side  is 
raised  (Bovvlby).  The  intervertebral  disks  are  apt  to  flatten  out 
on  the  concavity  of  the  curve.  In  very  rare  instances  lateral 
curvature  results  from  caries  of  a  half  of  one  or  of  several 
vertebrae.  In  a  spinal  tumor  lateral  curvature  may  occur, 
the  concavity  of  the  bend  being  on  the  side  of  the  growth. 
Symptoms. — An  ordinary  case  of  spinal  curvature  from 
weak  muscles  comes  on  gradually  with  stooping,  and  after 
a  time  with  pain  in  the  dorsal  and  lumbar  regions 
and  weakness  in  the  back.  The  pain  is  made  more 
severe  by  walking  or  by  sitting  long  in  one  atti- 
tude. Anaemia  is  manifest,  and  walking  is  awkward 
and  ungraceful.  When  the  shoes  and  clothing  are 
removed,  and  the  child  stands  with  its  back  toward 
the  surgeon  and  the  feet  symmetrically  together, 
the  lower  angle  of  the  right  scapula  (in  a  dorsal 
curvature  to  the  right)  is  unduly  prominent  and  is 
Fig.  'i-.-  elevated  above  the  left ;  the  normal  prominence  of 
Lateral  Dor-  ^]^g  jgf|-  \\[^q^  crcst  is  lost ;  thc  right  iliac  crest  is 

sal  Curvature 

to  the  Right,  unduly  distinct ;  on  marking  the  spinous  processes 
sltlry^'Tum-  with  au  auilinc  pencil  the  curve  becomes  manifest ; 
bar  Curve  to  tendemcss  is  often  developed  on  pressing  the  spines ; 

the  Left.  ^  ^  . 

the  normal  dorsal  antero-posterior  curve  is  exag- 
gerated ;  the  abdomen  is  protuberant ;  the  chest  is  flat- 
tened;  the  neck  juts  forward;  and  the  breast  on  the  same 
side  as  the  concavity  of  the  curve  is  more  prominent  and 
on  a  lower  level  than  the  other  breast.  Always  observe  if 
the  anterior  iliac  spines  are  on  a  level  or  not,  and  always 
measure  the  length  of  the  legs.  The  patient,  with  the  knees 
extended,  bends  forward  with  the  arms  hanging  loosely  :  the 
erector  spinae  muscle  between  the  iliac  crest  and  the  last  rib 
is  seen  to  be  more  prominent  on  the  convexity  of  the 
lumbar  curve   than  on  its    concavity  (Bernard  Roth),   and 


SURGERY  OF   THE   SPINE.  57 1 

the  angles   of  the    ribs   on   the   side    of  the    convexity  of 
the    dorsal    curve    are    on    a    higher    level    than    are    those 
on    its    concavity.     Have    the    child    assume  what    it   sup- 
poses to  be  an  erect  attitude,  and  let  the  surgeon  correct 
this  into  the  best  possible  position  (Roth),  and  see  how  long 
it  can   voluntarily  be   maintained.     A  large  percentage   of 
these  patients  labor  under  pes  planus.     When  there  is  no 
osseous  deformity  (that  is,  when  the  surgeon  can  correct  the 
deformity),  and  when  the  spinal  muscles  are  not  paralyzed, 
the  prognosis  is  good  for  complete  cure.     Roth  states  that 
cases  without  osseous  deformity  can  practically  be  cured  in 
one  month,  but  the  treatment  must  be  continued  for  one 
year  to  prevent  relapse.^     In  cases  of  moderate  osseous  de- 
formity the  patient  can  be  improved  vastly  by  three  months' 
daily  treatment  (Roth).    Even  in  severe  cases  of  bony  deform- 
ity the  pain  may  be  relieved  and  the  deformity  be  modified. 
Treatment. — If  one  leg  is  too  short,  let  the  patient  wear 
a  thick-soled   shoe.     No   treatment   for  weak   muscles   has 
ever  been   devised  so  utterly  irrational   and   absurd  as  the 
prevention  of  all  movement;  and  neglect  of  all  treatment  for 
lateral  curvature  does  less  harm  than  immobilizing  the  spinal 
muscles  by  braces  and  supports.     The  muscular  nutrition 
in  these  cases  is  to  be  restored,  as  is  muscular  nutrition  in 
any  other  region,  by  scientific   gymnastics,   electricity,  the 
douche,  salt  baths,  frictions,  and  massage.     Roth's  advice  is 
to  so  re-educate  the  muscular  sense  that  a  patient  can  again 
know  whether  she  is  or  is  not  standing  straight ;  to  maintain 
an  improved  position  in  sitting  and  standing;  to  use  such 
clothing  as  will  not  interfere  with  the  assumption  of  a  normal 
attitude ;  to  enforce  systematic  training  of  the  muscles  of 
the  spine  and  thorax ;  and  to  give  attention  to  the  general 
health.     In    those   rare   lateral   curvatures   due  to   caries   a 
supporting  apparatus  must  of  course  be  applied. 

*  Heath's  Dictionary  of  Practical  Surgery. 


5/2  A   MANUAL    OF  SURGERY. 

Antero -posterior  curvature  (not  from  spinal  caries  or 
from  hip-joint  disease)  is  an  increase  of  the  normal  antero- 
posterior curves.  Increase  of  the  dorsal  curve  is  posterior 
curvature,  kyphosis,  or  excurvation  (Fig.  134,  a)  ;  increase  of 
the  lumbar  curve  is  anterior  curvature,  lordosis,  or  saddle- 
back (Fig.  134,  b).  Both  lordosis  and  kypho- 
sis are  apt  to  be  present.  Scoliosis  has 
nearly  always  some  antero-posterior  curva- 
ture associated  with  it.  Lordosis  is  apt  to 
be  compensatory,  to  prevent  the  centre  of 
gravity  going  too  far  forward.  Lordosis  is 
found  in  pregnant  women  and  in  very  fat 
men.  In  an  old  man  kyphosis  arises  from 
Fig.  i34.-Kyphosis  flattening  out  of  the  vertebral  disks  from 
(A)  and  Lordosis  (b).  pj-essurc.  Rhcumatic  gout  may  cause  it. 
Antero-posterior  curvature  is  often  due  to  paralysis  of  the 
erector  spinse  mass  (from  infantile  paralyses).  Pseudo- 
hypertrophic paralysis  causes  lordosis. 

Symptoms  and  Treatment. — The  symptoms  of  antero-pos- 
terior curvature  are  as  follows  :  The  thorax  is  flattened  or 
pigeon-breasted ;  the  shoulder-blades  are  widely  separated 
and  the  scapular  angles  project ;  the  abdomen  is  protuberant ; 
the  patient  complains  of  backache  and  soon  tires.  A  recent 
kyphosis  disappears  when  the  patient  lies  upon  his  stomach. 
The  fact  that  the  erector  spinae  muscles  are  soft,  and  the 
absence  of  pain  on  concussion  transmitted  from  the  heels, 
separate  kyphosis  from  caries.  Lordosis  is  unmistakable. 
When  the  spine  is  movable,  employ  the  same  plan  of  treat- 
ment as  that  in  lateral  curvature,  suiting  the  gymnastics 
to  the  deformity  (Roth).  In  painful  kyphosis  with  partial 
ankylosis,  endeavor  to  make  the  ankylosis  complete  to  pre- 
vent pain,  obtaining  this  result  by  applying  a  plaster  jacket 
which  laces  up  and  letting  the  patient  wear  it  for  several 
years. 


SURGERY  OF    THE   SPINE.  573 

Ang-ular  curvature  (spinal  caries,  Pott's  disease),  which 
is  strumous  caries  of  the  vertebral  bodies,  occurs  particularly 
in  children  who  are  scrofulous,  but  it  may  arise  at  any  age. 
The  dorso-lumbar  region  is  most  prone  to  suffer.  The  causes 
are  struma  and  syphilis.  Blows  or  strains  are  often  exciting 
causes.     It  may  develop  after  an  exanthematous  fever. 

The  cancellous  tissue  of  the  anterior  portion  of  a  verte- 
bral body  becomes  primarily  carious,  or  the  inflammation 
may  begin  in  an  intervertebral  disk.  (The  changes  of 
strunious  osteitis  have  previously  been  set  forth.)  The 
body  of  the  vertebrae  and  the  adjacent  vertebral  disks  are 
destroyed,  and  the  process  extends  to  adjacent  vertebrae. 
The  weight  which  rests  upon  the  spinal  column  crumbles 
down  softened  bone,  compresses  the  diseased  vertebrae  and 
disks,  and  produces  angular  deformity  (the  anterior  part  of 
the  spine  formed  by  the  vertebral  bodies  is  shortened,  the 
posterior  part  is  not,  and  hence  the  spines  project).  In  some 
cases  the  disease  is  spontaneously  arrested  by  organization 
of  inflammatory  products,  and  ankylosis  (fibrous  or  bony)  in 
deformity  is  Nature's  cure.  In  most  cases,  however,  the  dis- 
ease spreads  and  caseous  pus  is  formed,  which,  according  to 
the  route  it  takes,  causes  lumbar  abscess,  dorsal  abscess, 
psoas  abscess,  or  post-pharyngeal  abscess  (pp.  98,  99).  In 
some  cases  the  spinal  cord  is  compressed,  but  in  most  cases 
it  is  not,  and  even  when  it  is  compressed,  paraplegia  is  rare 
and  is  usually  temporary.  Pachymeningitis  is  apt  to  arise. 
Caries  of  the  cervical  region  constitutes  a  more  dangerous 
disease  than  caries  of  either  the  dorsal  or  the  lumbar  reorions 
(dangerous  pressure  occurs  more  easily).  Death  may  be 
caused  by  exhaustion,  sepsis,  hemorrhage,  amyloid  disease, 
pneumonia,  peritonitis,  pleuritis,  tubercular  dissemination,  and 
pressure  upon  the  cord. 

Symptoms. — The   first  symptom  of  angular  curvature  is 
pain  in  the^back,  which  is  increased  by  motion,  by  pressure, 


574  A   MANUAL    OF  SURGERY. 

and  by  vertebral  jars.  Neuralgic  pains  pass  into  distant 
parts  (sciatica,  intercostal  neuralgia)  and  are  often  linked  with 
muscular  spasm.  In  cervical  caries  there  is  often  wry-neck. 
Cramp  in  the  legs  occurs  in  dorsal  or  lumbar  caries.  The 
patient,  if  a  child,  grows  tired  easily,  shows  alteration  of  dis- 
position, becomes  moody  and  irritable,  complains  of  vague 
pains  in  many  places,  constantly  leans,  rests,  or  lies  down, 
and  walks  with  the  back  rigid,  which  produces  a  peculiar 
gait.  If  asked  to  pick  up  something  from  the  ground,  the 
child  will  not  bend  the  back,  but  bends  the  knees  or  gets 
upon  the  knees  instead.  A  painful  spot  is  found  by  pressing 
upon  the  spines,  and  the  same  spot  is  painful  on  pressing  the 
head  downward  or  upon  jarring  the  entire  spine.  Spasm  of 
the  erector  spinae  is  detected  (C.  Hilton,  Golding-Bird).  The 
pain  is  relieved  by  lifting  the  shoulders.  When  angular 
deformity  begins,  it  is  easily  recognized.  Paralysis  may 
exist,  and  it  is  due  to  pachymeningitis  more  often  than  to 
pressure  from  bone.  Cervical  caries  causes  dyspncea  and 
torticollis,  the  head  requiring  support  with  the  hand.  Dys- 
phagia indicates  abscess.  In  adults  the  first  signs  of  Pott's 
disease  to  attract  attention  are  backache,  neuralgia,  girdle- 
pain,  cramp,  or  even  paralysis. 

Treatment  of  Caries  of  the  Spine. — When  recent  caries  of 
the  spine  is  active  and  affects  a  child,  when  it  is  accom- 
panied with  pain  and  fever,  and  when  paralysis  threatens, 
insist  upon  perfect  rest.  Place  the  child  supine  on  a  hard 
mattress,  and,  if  possible,  take  it,  while  still  in  bed,  out  of  doors 
daily.  Leeches,  blisters,  or  the  hot  iron  over  the  area  of 
pain  may  do  good.  When  the  disease  is  not  active  or  when 
it  arises  in  an  adult,  apply  Sayre's  plaster-of-Plaster  jacket 
(Fig.  135).  When  "all  subjective  signs  cease"  (Golding- 
Bird),  substitute  for  Sayre's  jacket  a  felt  jacket  which  laces. 
In  diseases  at  or  near  the  vertebro-occipital  articulation,  as 
long  as  dyspnoea  persists,  keep  the  patient  supine  with  a 


SURGERY  OF  THE   SPINE.  575 

small  hard  pillow  under  the  nape  of  the  neck  (Hilton)  and 
a  sand-bag  on  each  side  of  the  head  and  neck.  After  sev- 
eral months  mechanical  support  can  be  given  by  Furneaux 
Jordan's  apparatus.  In  disease  of  the  cervical  region  below 
the  axis,  or  in  cervico-dorsal  disease,  use  Sayre's  jury-mast 


Fig.   136. — Plaster-of-Paris   Jacket 
Fig.  135. — Plaster-of-Paris  Jacket  (Sayre).  and  Jury-mast  Applied  (Sayre). 

(Fig.  136).  Treat  abscesses  as  indicated  on  pages  98  and  99. 
Treves's  operation  for  caries  will  be  found  upon  page  479. 
Paralysis,  if  due  to  cord-inflammation,  is  treated  by  iodide 
of  potassium,  absolute  rest,  and  counter-irritation.  During 
the  course  of  Caries  of  the  spine,  give  oleum  morrhuae,  tonics, 
and  nutritious  food,  and  try  to  get  the  patient  out  often  into 
the  fresh  air.  Sea-air  is  very  beneficial.  When  all  active 
disease  ceases,  and  angular  curvature  only  remains,  use  an 
apparatus  to  combine  extension  with  mechanical  support,  the 
plaster  jacket  being  generally  employed. 

Injuries  of  spinal  lig-aments  and  muscles,  which  may 
complicate  more  serious  injuries  or  may  exist  alone,  are 
caused  by  wrenches,  twists,  and  violent  muscular  efforts  (as 
in  lifting).   _  Railway  accidents  may  be  responsible  for  these 


576  A   MANUAL    OF  SURGERY. 

sprains  and  strains.  The  symptoms  soon  after  the  accident 
are — considerable  shock,  as  a  rule,  even  hysterical  excite- 
ment ;  pain,  which  is  felt  in  the  back  and  often  shoots  into 
the  extremities,  and  which  is  much  increased  by  moving  the 
muscles;  tenderness;  muscular  rigidity,  which  in  one-sided 
lesions  is  unilateral  (unilateral  rigidity  cannot  be  simulated); 
and  often,  but  not  always,  swelling  and  discoloration.  The 
vertebral  spines  are  regular  and  are  not  mobile.  There  is  no 
distant  paralysis  or  hyperaesthesia  unless  the  cord  is  damaged 
(though  in  some  rare  cases  the  bladder  and  the  rectum  are 
paralyzed  when  no  cord-lesion  can  be  detected),  and  hyper- 
aesthesia may  exist  over  the  spines.  The  treatment  of  recent 
injuries  comprises  rest;  the  ice-bag  and  leeching  over  the 
painful  area ;  in  a  day  or  two  hot  fomentations,  tincture  of 
iodine,  and  inunctions  of  ichthyol  and  lanolin  ;  and,  later, 
massage,  the  douche,  and  frictions  with  a  stimulating  oint- 
ment. Phenacetin  relieves  pain,  though  in  some  cases  opium 
is  necessary.  The  injury  is  called  "  railway  spine  "  when  it 
is  caused  by  a  railway  accident. 

After  the  immediate  effects  of  the  accident  subside,  trau- 
matic neurasthenia  is  apt  to  arise.  In  this  condition  the 
patient  grows  tired  easily  and  complains  of  pains  and  aches 
in  the  back  and  loins,  interfering  with  or  preventing  work ; 
paraesthesia  and  numbness  exist  in  the  extremities ;  in  many 
cases  sexual  intercourse  is  impossible  because  of  premature 
ejaculation  or  of  incapacity  for  erection  ;  there  are  dyspepsia, 
eye-strain,  insomnia,  loss  of  memory,  rapid  and  irregular 
pulse,  cardiac  palpitation,  and  mental  depression  or  con- 
fusion. The  reflexes  are  usually  exaggerated,  but  they  can 
be  exhausted  more  easily  than  can  the  exaggerated  reflexes 
of  organic  cord  disease  (because  of  irritable  weakness).  Some 
rigidity  and  tenderness  exist  in  the  back,  and  the  skin  over 
this  region  is  often  hyperaesthetic.  Attacks  of  retention  of 
urine  may  occur.     Hypochondria  is  not  unusual. 


SURGERY  OF   THE   SPIXE.  57/ 

TrLiitmciit  of  Traumatic  Neiirastlicnia. — Rest,  tonics,  mas- 
sage, douches,  and  frictions  to  the  back.  Secure  sleep,  and 
endeavor  to  bring  about  a  gain  in  weight.  If  sexual  inca- 
pacity or  seminal  emissions  worry  the  patient,  dilate  the 
urethra  with  steel  bougies. 

Traumatic  hysteria  develops  only  in  those  predisposed  by 
a  neuropathic  hereditary  tendency;  traumatic  neurasthenia 
may  arise  in  anybody.  In  the  first  disease  the  accident  is 
only  the  exciting  cause ;  in  the  second  disorder  it  is  the 
cause'.  Many  cases  of  so-called  "  railway  spine  "  are  really 
examples  of  traumatic  hysteria.  Traumatic  hysteria  and 
neurasthenia  may  be  associated.  Neurasthenia  is  a  con- 
dition of  exhaustion  associated  with  a  number  of  chronic 
disorders ;  it  forms  a  foundation  on  which  hvsteria  loves 
to  build  its  structure  of  morbid  impressionability,  hyper- 
aesthetic  centres,  lowered  self-control,  and  sensitive  peripheral 
nervous  system.  The  accident  plays  a  double  part  in  pro- 
ducing traumatic  hysteria :  first,  by  its  effect  on  the  mind 
(psychical  traumatism) ;  second,  by  its  effect  on  the  body, 
which  anchors  the  attention  at  one  point,  and  this  area  of 
pain  or  stiffness  often  serves  as  an  auto-suggestion  which 
undergoes  morbid  magnification  wdien  viewed  through  the 
distorting  medium  of  hysteria.  Erichsen  used  to  teach 
that  the  varied  s}'mptoms  of  what  he  named  "  railway 
spine"  arose  from  inflammation  of  the  cord  and  its  mem- 
branes. A  blow  given  to  a  hysterical  person  causes  a 
feeling  of  numbness,  and  this  negative  sensation  from  local 
shock  may  establish  the  idea  of  paralysis,  or  the  traumatism, 
acting  as  a  suggestion,  inhibits  motor  representations  and 
destroys  the  normal  ideas  of  motion  and  feeling  (Charcot 
and  Pitre).  Terror  always  causes  a  feeling  of  loss  of  power 
in  the  legs,  and  the  terror  of  the  accident  may  thus  develop 
the  idea  of  paraplegia.  The  site  of  a  traumatism  may 
locahze  symptoms ,  for  instance,  a  blow  upon  the  eye  may 

■67 


5/8  A   MANUAL    OF  SURGERY. 

cause  amaurosis  or  blepharospasm.  It  is  important  to  re- 
member Charcot's  saying  that  a  hysteria,  long  latent  and 
unrecognized,  may  be  awakened  into  obvious  activity  by  a 
blow  or  an  accident.  Pitre  shows  the  same  to  be  true  of 
epilepsy.  A  not  unusual  lesion  is  hysterical  traumatic 
monoplegia,  not  coming  on  at  once  after  the  accident,  but 
usually  some  days  afterward,  and  presenting  flaccid  muscles, 
the  electrical  reactions  and  reflexes  remaining  normal,  but 
the  muscular  sense  being  lost  (Pitre).  The  muscles  usually 
waste.  The  skin  of  the  paralyzed  limb  is  anaesthetic  or 
analgesic.  There  may  be  anaesthesia  limited  to  a  limb, 
hemianaesthesia,  or  general  anaesthesia.^  Hysterical  paraly- 
sis is  usually  associated  with  the  permanent  stigmata  of 
hysteria — concentric  contraction  of  the  visual  field,  pharyn- 
geal anaesthesia,  convulsive  seizures,  and  hysterogenic  zones 
(Clarke  and  Pitre).  The  permanent  stigmata  may  be  latent. 
Hysterical  phenomena  lack  regularity  of  evolution,  and  they 
can  be  produced,  altered,  or  abolished  by  mental  influences 
or  by  physical  forces  which  produce  no  effect  on  organic 
disease.  In  most  hysterical  conditions  the  general  health  is 
not  profoundly  impaired.^ 

Treatment. — By  moral  means  chiefly.  Gain  the  confidence 
of  the  patient.  In  many  cases  separation  from  family  and 
friends  is  necessary  and  isolation  is  desirable.  The  Weir 
Mitchell  rest-cure  is  the  best  plan  of  treatment,  and  all  its 
details  should  be  carried  out  faithfully. 

Malingering-. — Persons  injured  in  accidents  are  often 
apt  to  pretend  to  maladies  which  do  not  exist.  Some  get 
well  upon  the  rendering  of  a  favorable  verdict  by  a  jury. 
In  any  case  always  examine  carefully,  so  as  to  be  able 
to  exclude  malingering.  Note  the  patient's  behavior  and 
motions  when  his  attention  is  diverted  from  his  disease. 
Me ningo-inye litis  can  be  excluded  if  there  be  no  spasm  nor 

^  J.  Michell  Clarke  in  Brain.         ^  Read  the  works  of  Thorburn  and  Pitre. 


SURGERY  OF   THE   SPINE.  579 

paralysis,  hyperaesthesi'a,  paraesthesia,  or  anaesthesia  at  a 
distance  (A.  Pearce  Gould).  If  pain  has  lasted  for  months, 
if  pressure  downward  upon  the  head  or  shoulders  does  not 
increase  pain,  if  the  vertebrae  are  movable  and  there  is  no 
angular  displacement,  exclude  caries.  Gould  states  that 
when  there  are  wasted  muscles,  when  moderate  spine-move- 
ment is  painless,  but  effort  in  bringing  the  body  erect  causes 
pain  in  the  erector  spinse  region,  the  trouble  is  a  sprain  of 
the  erector  spinae  muscle.  If  the  muscle  is  not  wasted,  and 
the  pain  is  in  bending  forward  rather  than  in  straightening 
up,  the  vertebral  ligaments  are  the  seat  of  trouble.  Unilateral 
spasm  cannot  be  simulated.  The  administration  of  ether  may 
dispose  of  a  pretended  paralysis. 

Concussion  of  the  Spinal  Cord. — This  term  has  no  def- 
inite pathological  meaning.  It  is  probable  that  the  condition 
is  one  of  laceration.  The  symptom  is  shock,  with  intense 
pallor,  nausea,  often  vomiting,  and  sometimes  syncope.  To 
this  condition  special  symptoms  may  be  linked — as  tempo- 
rary paralysis,  a  girdle-sensation,  numbness  and  loss  of 
power  in  the  limbs,  hiccough,  torticollis,  coarse  tremors, 
pains  in  the  back  and  limbs,  areas  of  anaesthesia  and  anal- 
gesia— depending  on  the  portion   of  cord  lacerated. 

Treatment. — The  treatment  in  concussion  of  the  spinal 
cord  is  the  same  as  that  for  sprains.  Traumatic  neurasthenia 
and  hysteria  or  organic  cord  disease  may  follow  this  injury. 

Contusion  of  the  spinal  cord  may  arise  from  a  sprain, 
but  it  is  usually  due  to  extreme  flexion  of  the  spine.  It 
causes  hemorrhage  into  the  gray  matter  of  the  cord  (haema- 
tomyelia).  The  symptoms  are  motor  and  sensory  palsy  and 
diminished  reflexes.  Some  cases  recover,  but  others  end  in 
myelitis. 

Wounds  of  the  spinal  cord,  which  are  rare,  are  usually 
fatal.  Wounds  above  the  origin  of  the  phrenic  nerves  cause 
almost  instant  death.     Gunshot  wounds  are  the  most  usual 


5  So  A   MANUAL    OF  SUKGEKY. 

form,  the  cord  being  damaged  by  the  bullet  and  by  bone- 
fragments.  A  knife  is  sometimes  thrust  in  between  the 
occiput  and  atlas. 

Compression  of  the  spinal  cord  may  be  due  to  blood 
or  to  l^miph.  Comprcssioii  from  blood  may  be  due  to  cxtra- 
mcdullary  hemorrhage  or  to  iiitramedidlajy  hemorrhage. 
Extramcdullary  hemorrhage  causes  sudden  pain  in  the  back, 
the  pain  radiating  from  compressed  nerve-roots ;  hyperces- 
thesia  and  paraesthesia  in  the  area  of  the  radiated  pain ; 
spasm  of  vertebral  muscles  supplied  by  the  compressed 
nerves,  sometimes  of  muscles  whose  nervous  supply  is  below 
the  lesion  ;  tremors  ;  convulsions  ;  retention  of  urine  ;  para- 
lytic symptoms  following  the  signs  of  irritation,  but  no 
absolute  paralysis  (Mills).  A  girdle -sensation  is  usual. 
Intraincdidlary  hemorrhage  causes  pain,  a  girdle-sensation, 
abolition  of  reflexes,  and  paralysis.  Spasms,  rigidity,  and 
paralysis  come  on  early.  Bed-sores,  retention  of  urine,  and 
incontinence  of  feces  may  occur. 

Treatment. — If  paralysis  from  spinal-cord  bleeding  ex- 
tends rapidly,  and  life  is  endangered  through  the  probable 
involvement  of  a  vital  centre,  perform  a  laminectomy  (White). 
In  some  cases  with  persistent  paraplegia  the  operation  should 
be  undertaken.  If  operation  is  not  undertaken,  cause  the 
patient  to  lie  upon  his  side  and  give  morphia  hypodermat- 
ically.  If  hemorrhage  continues  in  the  cord  and  if  the  patient 
be  plethoric,  perform  venesection.  Some  surgeons  advise 
hypodermatic  injections  of  ergotin.  To  promote  absorption 
of  the  clot  and  exudate,  give  a  combination  of  carbonate 
and  acetate  of  ammonium,  order  pilocarpine,  and  employ 
spinal  galvanism  and  the  hot  douche  (Bartholow). 

Fractures  and  dislocations  of  the  spine  are  very  rare. 
The  spinal  regions  most  liable  to  injury  are  the  atlo-axial, 
the  cervico-dorsal,  and  the  dorso-lumbar  (Treves).  A  verte- 
bra may  be  fractured  alone,  but  dislocation  without  fracture, 


SURGERY  OF   THE  SPINE.  58 1 

except  in  the  upper  cervical  region,  very  rarely  occurs. 
These  two  lesions,  dislocation  and  fracture,  are  so  often 
associated  that  the  tQvm.  fracture-dislocation  is  used  by  many 
surgeons  to  include  them  both.  The  causes  of  fracture  and 
dislocation  are  direct  force  (rarely)  and  indirect  violence 
(commonly).  Fracture-dislocation  from  direct  force  may 
occur  at  any  part  of  the  column,  and  in  this  accident 
the  posterior  vertebral  segments  are  driven  together.  The 
cord,  as  a  rule,  escapes.  Direct  force  may  damage  the  bones 
only.  Fracture-dislocations  from  indirect  force  most  com- 
monly happen  in  the  cervical  and  dorsal  regions.  In  the 
cervical  region  reduction  can  usually  be  secured,  but  in  the 
lumbar  region  reduction  is  impossible.  In  fractures  from 
indirect  force  the  cord  generally  suffers. 

Symptoms. — In  fracture-dislocations  much  displacement  is 
rare,  but  some  is  almost  always  recognizable  (irregularity  of 
spines  or  angular  deformity).  In  fractures  there  are  pain 
(which  is  increased  on  motion),  tenderness,  ecchymosis,  and 
motor  and  sensory  paralysis.  Priapism,  cystitis,  and  reten- 
tion of  urine  often  occur.  The  extent  of  paralysis  depends 
on  the  seat  of  the  cord-injury.  The  prognosis  depends  on 
the  amount  of  damage  done  to  the  cord.  Fracture-disloca- 
tions in  the  cervical  region  produce  obvious  deformity,  stiff- 
ness of  the  neck,  and  irregularity  of  the  spines,  and  a  dis- 
placed vertebra  may  occasionally  be  detected  by  a  finger 
in  the  pharynx.  Crepitus  can  rarely  be  detected  unless  a 
spinous  process  is  fractured. 

Treatment  of  Fracture-dislocations. — When  dislocation  ob- 
viously exists,  attempt  reduction  by  extension  and  rotation 
(White).  This  manoeuvre  is  very  dangerous  in  the  cervical 
region,  and,  as  deaths  have  happened,  some  eminent  sur- 
geons advise  against  reduction  when  the  injury  affects  that 
region.  In  fracture-dislocation  the  traditional  plan  is  to 
straighten  the  spine  gently  if  possible  and  to  put  the  patient 


582  A   MANUAL    OF  SURGERY. 

upon  his  back  upon  a  water-bed  or  upon  air-cushions.  In 
fractures  in  the  cervical  region,  support  the  head  and  neck 
with  sand-bags.  Empty  the  bladder  four  times  every  twenty- 
four  hours  with  a  soft  catheter  which  is  kept  strictly  aseptic. 
Take  every  precaution  to  prevent  bed-sores.  Some  sur- 
geons advocate  reduction  of  the  deformity  by  extension  and 
counter-extension,  and  by  the  application  of  a  firm-fitting 
but  removable  jacket  with  the  suspension  collar  (as  used  in 
Pott's  disease).  The  head  of  the  bed  is  raised  and  the  collar 
is  fastened  to  it.  Every  day  extend  gently  from  the  shoulders 
in  dorso-lumbar  fracture,  and  from  the  chin  and  occiput  in 
cervical  fractures.  Extension  may  be  maintained  perma- 
nently until  cure.  Prof  White  says  laminectomy  should 
be  performed  for  fracture  or  for  dislocation  when  there  is 
obvious  depression  of  the  vertebral  arches ;  in  all  cases  of 
pressure  upon  the  cauda  equina ;  when  there  are  character- 
istic symptoms  of  spinal  hemorrhage ;  and  in  some  cases 
where  rapid  degeneration  becomes  manifest. 

Operations  on  the  Spine  :  Treves' s  Operation  for  Verte- 
bral Caries. — (See  p.  479.) 

Laminectomy. — The  instruments  required  in  laminectomy 
are  dissecting-,  rat-toothed,  and  haemostatic  forceps ;  scalpels ; 
bone-cutting  forceps ;  rongeur  forceps ;  a  trephine ;  a  dry 
dissector;  a  periosteum-elevator  ;  sequestrum  forceps ;  small 
scissors,  straight  and  curved  on  the  flat ;  a  chisel  and  mallet ; 
retractors;  blunt  hooks;  a  probe;  tenaculum  forceps;  a 
spoon-curette;  a  sand  pillow;  fine  needles,  curved  and 
straight,  large  needles,  and  a  needle-holder. 

In  the  operation  of  laminectomy  the  patient  lies  prone  and 
a  sand  pillow  is  placed  under  the  lower  ribs.  Make  an 
incision  down  the  vertebral  spines,  the  middle  of  the  incision 
corresponding  to  the  seat  of  fracture.  The  sides  of  the 
spinous  process  and  the  laminae  are  cleared.  The  perios- 
teum is  incised  in  the  angle  between  the  laminae  and  spines, 


SURGERY  OF   THE   RESPIRATORY  ORGANS.  583 

and  it  is  lifted  away  from  the  arch.  The  spinous  processes 
are  cut  off  with  forceps  close  to  their  bases,  the  laminae  are 
divided  on  each  side  with  the  rongeur,  and  the  dura  is 
exposed.  In  some  cases  the  fragments  will  be  found  on 
exposing  the  vertebrae,  or  the  blood-clot  will  be  seen 
between  the  dura  and  the  bone  ;  in  other  cases  the  dura 
must  be  opened  with  scissors  vertically  in  the  middle  line 
while  it  is  grasped  with  rat-toothed  forceps.  After  reaching 
and  removing  the  compressing  cause,  or  after  failing  to  find 
or  remove  it,  close  the  dura  with  catgut,  drain  the  length  of 
the  wound  with  a  tube,  stitch  the  superficial  parts  with  silk- 
worm gut,  and  dress  antiseptically/ 


XXIV.    SURGERY  OF  THE    RESPIRATORY 

ORGANS. 

I.  Diseases  axd  Injuries  of  the  Nose  and  Antrum. 

Foreig-n  bodies  in  the  nose  are  usually  introduced 
through  the  anterior  nares,  but  in  rare  instances  they  enter 
by  way  of  the  posterior  nares.  Small  particles  are  often 
expelled  spontaneously ;  larger  pieces  gather  mucus  and 
become  fixed.     Some  materials  swell  after  lodgment. 

Treaiinejit. — Illuminate  the  nostril,  and,  if  the  foreign 
body  can  be  seen,  insert  a  hook  back  of  it  and  effect  its 
removal  by  means  of  forceps.  In  many  cases  anaesthesia  is 
required.  Some  foreign  bodies  require  to  be  pushed  back 
into  the  naso-pharynx.  Occasionally  expulsion  may  be 
effected  by  inserting  a  rubber  tube  into  the  unblocked  nos- 
tril and  telling  the  patient  to  blow  forcibly  through  it.  In 
serious  cases  a  specialist  should  be  summoned  to  remove  a 
portion  of  the  turbinated  bone  or  to  perform  whatever 
operation  he  thinks  best. 

Inflammation   and  Abscess  of  the  Antrum   of  Hig-h- 

1  See  J.  W.^Vhite's  admirable  description  in  the  Annals  of  Surgery,  July,  1889. 


584  A   MANUAL    OF  SURGERY. 

more  (Maxillary  Antrura). — The  source  of  this  disease 
may  be  inflammation  of  the  nose  or  periostitis  around  the 
roots  of  the  teeth.  The  symptoDis  are  pain,  oedematous 
sweUing  of  the  face,  and  thinning  of  the  bone  so  that  it 
crepitates  under  pressure.  When  pus  exists,  certain  posi- 
tions of  the  head  will  cause  a  purulent  flow  from  the  nose, 
and  pus  may  be  seen  by  a  speculum  as  it  flows  into  the 
nose.  In  severe  cases  the  jaw  expands,  the  eye  protrudes, 
and  great  tenderness  of  the  alveolus  exists.  Percussion 
exhibits  a  dull  note.  In  the  diagnosis  it  may  be  well  to 
employ  an  electric  light  in  the  closed  mouth  and  note  the 
limitations  of  light-transmission. 

Treatment. — Before  pus  forms,  leech  and  use  hot  fomen- 
tations. When  pus  has  formed,  evacuate  it  at  once.  If  the 
disease  arises  from  a  carious  tooth,  pull  the  tooth  and  push 
a  trocar  through  its  socket  into  the  antrum.  If  the  teeth 
are  sound,  bore  a  hole  with  a  large  gimlet  or  with  a  bone- 
drill  above  the  root  of  the  second  bicuspid  tooth  and  one 
inch  above  the  edge  of  the  gum.  A  counter-opening  should 
be  made  into  the  inferior  nasal  meatus.  A  drainage-tube  is 
pulled  from  the  first  opening  into  the  nose  and  is  allowed  to 
protrude  from  the  nostril.  Irrigate  daily  with  peroxide  of 
hydrogen.  In  three  or  four  days  discontinue  through-and- 
through  drainage,  but  prevent  the  first  opening  from  closing 
until  the  discharge  ceases  to  be  purulent. 

2.  Diseases  and  Injuries  of  the  Larynx  and  Trachea. 
CEdema  of  the  Larynx  (CEdema  of  the  Glottis). — The 
causes  of  oedema  of  the  larynx  are — acute  laryngitis  ;  chronic 
diseases,  such  as  tuberculosis  or  syphilis ;  inflammatory  dis- 
orders, such  as  diphtheria  and  erysipelas ;  acute  infectious 
diseases  ;  Bright's  disease  ;  aneurysm  ;  whooping-cough  ; 
pneumonia;  quinsy;  wounds  of  the  larynx;  wounds  of  the 
neck ;  scalds  and  burns  of  the  larynx.     The  symptonis  are 


SURGERY  OF   THE   RESPIRATORY  ORGANS.  585 

sudden  and  rapidly  increasing  dyspncea,  respiratory  stridor, 
huskiness  of  the  voice,  and  finally  aphonia.  The  epiglottis 
may  be  felt  with  the  finger  and  may  be  seen  with  a  mirror. 

Treatment. — In  cases  of  oedema  of  the  larynx  which  are 
not  excessively  acute,  make  multiple  punctures  into  the 
epiglottis  and  favor  bleeding  by  the  inhalation  of  steam. 
In  severe  cases  perform  intubation  or  tracheotomy. 

"Wounds  and  Injuries  of  the  Larynx. — The  larynx  may 
be  injured  internally  by  foreign  bodies,  and  externally  by 
blows  and  cuts.  A  condition  often  met  with  is  cut  iliroat, 
the  result  usually  of  a  suicidal  attempt  on  the  part  of  the 
patient  or  a  homicidal  effort  on  the  part  of  an  assailant. 
The  cut  of  the  suicide  is  usually  in  front ;  it  misses  the  great 
vessels,  but  divides  the  crico-thyroid  or  thyro-hyoid  mem- 
brane. The  epiglottis  may  be  incised,  or  even  be  cut  off 
If  a  large  vessel  is  cut,  death  rapidly  occurs.  The  immediate 
dangers  of  cut  throat  are  hemorrhage,  suffocation  by  blood, 
entrance  of  air  into  veins,  and  suffocation  by  displacement 
of  parts.  The  secondary  dangers  are  pneumonia,  infection 
and  sepsis,  exhaustion,  and  secondary  hemorrhage.  The 
remote  dangers  are  stricture  and  fistula  (Keetley). 

Treatment. — In  wounds  of  the  throat,  arrest  hemorrhage, 
remove  clots  from  the  larynx  and  trachea,  bring  about 
reaction,  asepticize  the  parts  as  well  as  possible,  suture  the 
deeper  structures  with  catgut  and  the  superficial  parts  with 
silkworm  gut,  dress  antiseptically,  and  place  a  bandage 
around  the  head  and  chest,  so  as  to  pull  the  chin  toward  the 
sternum.  If  laryngeal  breathing  is  much  interfered  with, 
perform  tracheotomy.  Feed  the  patient  through  a  tube 
until  union  has  well  advanced.  The  old  method  of  leaving 
the  wound  open  is  to  be  condemned.  When  sutures  are 
used,  primary  union  may  be  obtained. 

Foreign  Bodies  in  the  Air -passages. — The  lodgement 
of  foreign  bodies  in  the  air-passages  is  a  frequent  accident. 


586  A   MANUAL    OF  SURGERY. 

Small  solid  bodies  are  usually  expelled  by  coughing. 
Liquids  and  solids  rarely  pass  beyond  the  larynx  (except 
in  laryngeal  disease  or  palsy,  wounds  of  the  floor  of  the 
mouth,  cut  throat,  and  in  people  unconscious  or  comatose). 
In  post-ether  vomiting  or  in  the  vomiting  of  drunkards  the 
vomited  matter  may  find  its  way  into  the  larynx.  In  most 
instances  of  foreign  bodies  lodged  in  the  air-passages  it 
will  be  found  that  the  object  was  being  held  in  the  mouth 
when  a  sudden  deep  inspiration  was  taken  (often  from 
laughter).  The  syniptoms  are  immediate,  due  to  obstruction 
by  the  body  and  to  spasm,  and  secondary,  due  to  the  situa- 
tion of  the  body  and  the  changes  it  undergoes  or  induces. 

Lodgement  in  the  pharynx  causes  violent  dyspnoea.     The 
body  can  be  seen  or  felt. 

Lodgement  in  tJie  Larynx. — In  a  severe  case  the  patient 
fights  madly  for  air ;  his  face  becomes  livid  and  cyanotic ; 
his  veins  stand  out  prominently ;  speech  is  impossible, 
though  he  may  make  noises  and  utter  harsh  cries  ;  violent 
coughing  begins,  and  then  vomiting;  he  tries  to  force  a 
finger  down  his  throat  and  clutches  at  his  neck ;  sweat 
pours  from  him  ;  he  feels  a  sense  of  impending  dissolution, 
and  he  falls  down  unconscious,  with  incontinence  of  feces 
and  urine.^  In  a  less  severe  case  violent  dyspnoea  gradually 
departs  and  the  patient  lies  exhausted,  but  dyspnoea  and 
cough  are  liable  to  recur  suddenly  at  any  time  because  of 
spasm,  and  they  may  be  induced  by  a  change  of  position. 
These  attacks  of  fierce  spasmodic  cough  are  not  at  first 
linked  with  expectoration,  but  after  inflammation  begins 
there  is  a  profuse  and  often  bloody  expectoration.  Inflam- 
mation follows  more  rapidly  the  lodgement  of  a  sharp  or 
irregular  body  than  it  does  that  of  a  round  or  smooth 
body.  Inflammation  is  apt  to  produce  oedema  of  the  glottis, 
broncho-pneumonia,  or  ulceration  and  necrosis  of  the  larynx. 
1  See  C.  Mansell  Moullin's  graphic  description. 


SURGERY  OF  THE   RESPIRATORY  ORGANS.  587 

Any  foreign  body  in  the  larynx  may  at  any  moment  produce 
spasmodic  dyspnoea,  and  it  is  always  very  liable  to  cause 
oedema  of  the  glottis. 

Lodgevicnt  in  the  Trachea. — The  immediate  symptoms  of 
foreign  bodies  in  the  trachea  depend  on  the  shape  and 
weight  of  the  body,  and  whether  it  becomes  fixed  in  the 
mucous  membrane  or  moves  to  and  fro  with  the  air-cur- 
rent. A  smooth  heavy  body  falls  to  the  bifurcation,  and,  if 
it  does  not  enter  a  bronchus,  moves  with  every  breath,  and 
by  its  movement  causes  violent  laryngeal  spasm,  cough,  and 
whooping  inspiration  without  aphonia.  The  patient  is  often 
conscious  of  the  movements  of  the  foreign  body,  and  the 
surgeon  may  detect  them  with  the  stethoscope.  A  foreign 
body  in  the  trachea  is  liable  to  cause  death  by  dyspnoea,  or 
it  may  ascend  so  as  to  be  caught  in  the  larynx,  or  may  even 
be  expelled.  Irregular  or  sharp  bodies  lodge  in  the  mucous 
membrane,  produce  inflammation,  frequent  cough,  and  ex- 
pectoration, and  finally  lead  to  ulceration.  Bodies  which 
swell  up  from  heat  and  moisture  tend  to  lodge  and  to  become 
fixed  (seeds  may  sprout). 

Lodscenicnt  in  a  Bronchus. — Foreijjn  bodies  in  the  bronchi 
usually  lodge  in  the  right  bronchus.  When  a  small  lung- 
area  is  obstructed,  the  obstructed  side  shows  diminished 
respiratory  mov^ement  and  murmur  with  occasional  whistling 
sounds  and  large  moist  rales  ;  percussion  note  is  normal. 
When  an  entire  lobe  is  obstructed,  all  respiratory  sounds 
are  absent  over  it,  and  over  the  unobstructed  lung  respira- 
tion is  exaggerated ;  the  percussion  note,  at  first  resonant, 
becomes  dull.  Lodgement  in  a  bronchus  may  cause  broncho- 
pneumonia, abscess,  hemorrhage,  and  even  gangrene. 

Treatment. — If  a  foreign  body  lodges  in  the  pharynx,  try 
to  pull  it  forward  ;  \{  this  fails,  push  it  back  into  the  oesoph- 
agus. In  lodgement  in  the  larynx  or  below,  if  the  symptoms 
are  very  urgent,  at  once  perform  a  quick  laryngotomy.    If 


588  A   MANUAL    OF  SURGERY. 

the  symptoms  are  not  so  urgent,  get  a  complete  history  of 
the  accident  and  find  out  the  nature  of  the  foreign  body. 
Be  sure  a  foreign  body  is  retained  in  the  respiratory  tract,  and 
determine  what  its  situation  may  be.  Often  a  skilful  man 
can  remove  a  foreign  body  from  the  larynx  by  means  of 
forceps,  a  mirror  being  used  for  illumination.  The  fauces 
and  upper  portion  of  the  larynx  should  have  cocaine  applied 
to  them  to  lessen  pain  and  spasm.  If  the  surgeon  fails  in 
extraction  by  forceps,  and  laryngotomy  has  been  performed, 
continue  the  search  through  the  opening  in  the  crico-thyroid 
membrane  ;  if  laryngotomy  has  not  been  performed,  let  it  be 
done  in  the  form  known  as  tliyrotoniy  (a  vertical  incision 
between  the  alse  of  the  thyroid  cartilage,  and  the  separation 
of  these  alae  to  permit  of  exploration).  After  a  thyrotomy 
suture  the  perichondrium  with  catgut.  If  the  foreign  body 
is  in  the  trachea  or  in  a  bronchus,  perform  tracheotomy : 
this  prevents  suffocation  from  laryngeal  spasm  or  oedema. 
The  foreign  body  may  be  expelled ;  if  it  is  not  expelled, 
search  the  trachea  and  bronchi  with  Gross's  forceps,  with 
probes,  with  hooks,  or  with  the  finger.  If  the  foreign  body 
cannot  be  found,  insert  a  tube,  put  the  patient  to  bed,  and 
maintain  a  moist  atmosphere.  If  the  foreign  body  be  ex- 
tracted, do  not  insert  a  tube  (unless  oedema  of  the  glottis 
exists  or  is  likely  to  come  on),  do  not  suture  the  wound, 
but  cover  it  with  moist  gauze  and  let  it  heal  by  granulation. 
Morphia  and  sedative  cough-mixtures  are  given.  Gross  says 
that,  even  when  a  foreign  body  has  long  been  retained,  an 
operation  should  be  performed  so  long  as  the  air-passages 
are  not  seriously  diseased. 

3.  Operations  on  the  Larynx  and  Trachea. 
Tracheotomy. — The  instruments  required  in  this  opera- 
tion   are    the    scalpel,    dissecting-forceps,    a    dry    dissector, 
haemostatic  forceps,  scissors,  a  tenaculum,  aneurysm-needle, 


SURGERY  OF   THE   RESPIRATORY  ORGANS. 


589 


tubes,  tapes,  Pacquelin  cautery,  needles,  needle-holder,  a 
mouth-gag,  tongue-forceps,  foreign-body  forceps,  retractors, 
and,  if  membrane  is  present,  feathers  and  a  solution  of  bicar- 
bonate of  sodium.  In  a  formal  operation  give  chloroform, 
but  in  an  emergency  case  this  cannot  be  done.  The  patient 
may  be  placed  supine  with  a  sand  pillow  under  the  neck 
and  with  the  head  thrown  over  the  end  of  the  table.  In  a 
child,  Liston  would  wrap  it  up  to  the  neck  in  a  sheet  to 
prevent  movements  of  the  limbs,  would  seat  himself  on  a 
chair,  place  the  child  upon  the  nurse's  lap,  and  take  its  head 
between  his  knees.     If  bleeding  is  profuse  when  the  surgeon 


r^^ 


^4Thyr.i„f.    \  :/ 
'^  Itnc 

Fig.  137. — Blood-supply  of  the  Larynx  and         Fig.  13S. — Parts  Exposed  in  Tracheotomy 
Trachea  (Esmarch  and  Kowalzig).  (Esmarch  and  Kowalzig). 

is  ready  to  open  the  trachea,  place  the  patient  in  the  Trendel- 
enburg position  with  the  neck  extended.  The  head  must 
be  exactly  in  the  middle  line,  and  extended  (in  an  adult  this 
gives  two  and  three-quarter  inches  of  trachea  above  the 
manubrium  ;  in  a  child  of  ten,  two  and  a  quarter  inches ;  in 
a  child  of  six,  about  two  inches).  The  operator  stands  upon 
the  right  side  when  the  patient  is  supine.  The  trachea  may 
be  opened  above  or  below  the  isthmus  of  the  thyroid  gland. 
The  isthmus  in  an  adult  usually  lies  over  the  second  and 


590  A    MANUAL    OF  SURGERY. 

third  rings  (Fig.  137).  The  isthmus  in  a  child  usually  lies 
over  the  first  ring  or  even  over  the  space  between  the  cricoid 
cartilage  and  the  first  ring.  The  high  operation  is  always 
performed  except  in  cases  where  it  is  desired  to  search  for 
a  foreign  body  in  a  bronchus. 

High  Tracheotomy. — This  operation  is  preferred  because 
in  this  region  the  muscles  are  distinctly  separated  (Fig.  138), 
the  main  vessels  of  the  neck  and  the  inferior  thyroid  vessels 
are  not  encountered,  the  anterior  jugular  veins  are  small  and 
have  very  few  transverse  branches,  and  the  trachea  is  near  the 
surface  (Treves).  Accurately  locate  the  cricoid  and  thyroid 
cartilages.  An  incision  is  begun  at  the  upper  border  of  the 
cricoid  cartilage,  and  is  carried  down  precisely  in  the  middle 
line  for  about  one  and  a  half  inches.  Treves  advises  the 
operator  to  steady  the  skin  of  the  neck  with  the  fingers  of 
the  left  hand  and  to  cut  with  the  unsupported  right  hand  (if 
the  hand  be  supported  the  respirations  will  interfere  with 
the  operation).  Incise  the  skin,  the  superficial  fascia,  and 
the  anterior  layer  of  the  cervical  fascia,  separate  the  sterno- 
hyoid and  sterno-thyroid  muscles,  and  divide  the  fascia  over 
the  trachea.  This  fascia  is  attached  above  to  the  thyroid 
cartilage,  and  it  divides  below  into  two  layers  to  invest  the 
thyroid  body  and  its  isthmus.  If  veins  are  in  the  line  of  the 
incision,  push  them  aside,  but  do  not  stop  to  apply  a  double 
ligature.  Even  if  bleeding  is  profuse,  as  soon  as  the  trachea 
is  opened  and  air  enters  freely  into  the  lungs  venous  conges- 
tion is  relieved  and  bleeding  is  apt  to  cease.  If  hemorrhage 
be  violent  and  the  veins  are  not  at  once  caught  by  forceps, 
it  may  be  well  to  place  the  patient  in  the  Trendelenburg 
position.  Before  opening  the  trachea,  push  the  isthmus  of 
the  thyroid  gland  down  ;  if  it  cannot  be  pushed  down  suf- 
ficiently, make  a  transverse  incision  through  the  fascia  at  the 
upper  border  of  the  cricoid  cartilage,  and  lift  the  fascia,  and 
the  isthmus  with    it,  off  the   trachea.     Insert  a  tenaculum 


SURGERY  OF   THE   RESPIRATORY  ORGANS.  59 1 

into  the  oricoid  cartilage  in  order  to  steady  the  tube.  Turn 
the  back  of  the  knife  toward  the  sternum,  hold  a  finger  on 
the  blade  to  prevent  too  deep  a  cut  being  made,  plunge  the 
knife,  like  a  trocar,  into  the  mid-line  of  the  trachea  above  the 
isthmus,  and  divide  two  or  three  rings.  Do  not  remove  the 
hook  at  this  time.  If  a  foreign  body  is  present,  try  to  re- 
move it ;  if  success  attends  the  effort,  no  tube  need  be  worn, 
but  if  the  body  is  not  found,  use  a  tube.  In  croup  or  in 
diphtheria,  remove  membrane  (by  means  of  a  feather  and  a 
solution  of  bicarbonate  of  sodium  5ij,  glycerin  5J,  water  3x — 
Parke)  and  insert  a  tube.  Grasp  an  edge  of  the  cut  with 
the  dissecting-forceps,  include  the  mucous  membrane  in  the 
bite,  bring  the  head  erect,  introduce  the  tube,  and  remove  the 
tenaculum.  Secure  the  tube  by  tapes,  and  suture  the  wound 
below  the  tube.  Remove  the  tube  at  the  first  moment  con- 
sistent with  safety.  In  croup  or  diphtheria,  put  a  screen 
around  the  bed ;  have  the  air  moist  by  steam ;  remove  the 
inner  tube  and  clean  every  two  or  three  hours  at  first ;  clean 
the  outer  tube,  and  the  larynx  and  trachea  whenever  re- 
quired, by  means  of  a  feather  and  Parke's  solution.  A  steam 
spray-atomizer  may  very  often  be  used  with  advantage.^ 

Quick  laryngotomy  must  never  be  attempted  upon  a 
child  under  thirteen  years  of  age,  because  of  the  small  size 
of  the  crico-thyroid  space  before  this  age  (Treves).  In 
view  of  the  difficulty  of  introducing  a  tube  and  of  wearing 
it  so  near  the  vocal  cords,  laryngotomy  should  not  be  per- 
formed for  croup,  diphtheria,  or  for  any  condition  in  which 
a  tube  must  be  worn  long.  An  incision  an  inch  and  a 
quarter  long  is  made  in  the  middle  line,  from  above  the 
lower  edge  of  the  thyroid  cartilage  to  below  the  lower 
border  of  the  cricoid.  Divide  the  skin,  superficial  fascia, 
and  deep  fascia,  separate  the  crico-thyroid  and  sterno-thy- 

1  See  Mr.  Jacobson's  admirable  comments  upon  the  croup-tent  and  the  after- 
treatment  of  tracheotomy. 


592  A   MANUAL    OF  SURGERY. 

roid  muscles,  divide  the  deep  layer  of  fascia,  and  divide  the 
crico-thyroid  membrane  horizontally  just  above  the  cricoid 
cartilage.  The  tube  must  be  shorter  than  is  the  tracheotomy- 
tube.  An  operation  which  opens  vertically  the  crico-thyroid 
membrane,  the  cricoid  cartilage,  and  the  upper  rings  of  the 
trachea  is  called  "  laryngo-tracheotomy." 

Intubation  of  the  Larynx  (O'Dwyer's  Operation). — The 
instruments  required  in  this  operation  are  a  mouth-gag,  an 
instrument  to  hold  the  tube  and  introduce  it,  an  instrument 
for  extracting  the  tube,  and  a  graduated  scale.  The  collar 
of  the  tube  has  a  perforation  through  which  a  piece  of  silk 
is  fastened  to  draw  out  the  tube.  The  child  is  wrapped  in 
a  sheet  to  secure  the  limbs,  is  seated  in  a  nurse's  lap,  and  its 
head  is  held  by  an  assistant.  Open  the  jaws  and  insert  the 
self-retaining  mouth-gag.  The  surgeon  sits  in  front  of  the 
patient,  wraps  the  index  finger  of  his  left  hand  with  plaster, 
and  passes  it  into  the  child's  mouth  until  his  finger  touches 
the  epiglottis.  Introduce  the  holder  and  tube  (observing  if  the 
silk  is  free)  along  the  surface  of  the  tongue  until  the  obturator 
touches  the  epiglottis ;  raise  the  epiglottis  with  the  left  index 
finger,  and  pass  the  tube  into  the  larynx ;  place  the  left  index 
finger  against  the  tube,  and  withdraw  the  holder  with  the 
right  hand.  Tie  the  silken  thread  to  the  ear,  and  direct  the 
nurse  to  employ  it  to  remove  the  obturator  if  it  becomes 
obstructed  or  is  coughed  up.  Remove  the  tube  in  two  or 
three  days ;  if  breathing  is  easy,  do  not  reintroduce  it,  but 
if  dyspnoea  recurs,  replace  the  tube  for  two  or  three  days 
more.  If,  in  introducing  the  tube,  a  mass  of  false  membrane 
is  pushed  before  it  into  the  trachea,  breathing  ceases,  and,  if 
the  mass  is  not  at  once  coughed  up,  tracheotomy  must  be 
performed.  Wharton  feeds  these  patients  on  semi-solids 
rather  than  upon  liquids  (mush,  soft  eggs,  and  corn-starch), 
and  if  trouble  occurs  in  swallowing  these  articles,  he  feeds 
by  the  rectum  or  by  means  of  a  tube  (Wharton). 


SURGERY  OF   THE   RESPIRATORY  ORGANS.  593 

4.  Diseases   and   Injuries   of   the    Chest,    Pleura,   and 

Lungs. 

Pleuritic  effusion  may  arise  from  foreign  bodies,  from 
injury  by  fragments  of  a  broken  rib,  from  tumors,  and  from 
inflammation  of  the  lung,  but  most  usually  from  pleuritis. 
Inflammatory  effusion  is  nearly  always  unilateral  (except  in 
tubercular  pleurisy,  which  is  one-sided  at  the  start). 

The  signs  of  pleuritic  effusion  are — dulness  on  percussion 
over  the  effusion,  this  dulness,  when  the  patient  is  erect, 
being  at  the  lower  part  of  the  chest  and  ascending  higher 
posteriorly  than  anteriorly  (alteration  of  position  alters  the 
situation  of  the  dulness) ;  the  intercostal  spaces  are  widened 
and  the  intercostal  depressions  are  obliterated ;  no  breath- 
sounds  can  be  detected  in  the  area  of  flatness  when  the  col- 
lection of  fluid  is  large,  but  in  small  effusions  deeply  situated 
the  breath-sounds  are  often  audible ;  the  percussion  note 
above  the  liquid  is  hyper-resonant  or  tympanitic,  and  is  often 
associated,  at  the  edge  of  the  liquid,  with  a  friction  sound; 
posteriorly,  high  up  and  near  the  spine,  there  is  bronchial 
respiration  and  bronchophony  (Prof  DaCosta).  In  these 
cases  pain  disappears  with  the  advent  of  effusion,  dyspnoea 
comes  on,  and  the  patient  lies  upon  the  diseased  side.  Cough 
and  fever  always  exist.  In  serous  effusions  the  diagnosis  may 
be  confirmed  by  the  introduction  of  an  asepticized  hypoder- 
matic needle.  The  treatment  in  this  stage  is  to  discontinue 
arterial  sedatives  and  to  stimulate  if  the  circulation  calls  for 
it.  The  exudation  is  removed  by  salines,  by  compound 
jalap  powder,  or  by  elaterium.  If  these  means  fail,  if  the 
efl'usion  is  excessive,  if  it  is  producing  dyspnoea,  or  if  pus 
forms,  at  once  aspirate. 

Empyema  is  a  collection  of  pus  in  the  pleural  cavity. 
Among  the  causes  of  empyema  are  those  of  serous  effusion. 
The  signs  are  dulness  on  percussion,  as  in  serous  effusion, 

38 


594  ^   MANUAL    OF  SURGERY. 

fever,  chills,  bulging  of  the  intercostal  spaces,  and  oedema  of 
the  skin  of  the  chest.  The  treatment  is  aspiration  or  incision 
and  drainage. 

Contusions  and  Wounds  of  the  Chest. — The  symptoms 
of  contusions  of  t/ie  cJicst  are  pain  and  soreness,  and,  as  a 
consequence,  abdominal  respiration  and  decubitus  upon  the 
back  inclining  to  the  injured  side.  In  severe  contusions 
the  viscera  may  be  injured.  The  treatment  is  by  strapping 
the  chest  as  for  fractured  ribs  (PI.  7,  Fig.  13).  Nojt-penetrat- 
ing  wounds  of  the  chest,  which  are  not  especially  grave,  are 
treated  according  to  general  rules,  the  chest  being  immo- 
bilized. Penetrati?ig  zuoitnds  are  very  grave  and  serious. 
Visceral  injury  may  be  inflicted.  Emphysema  is  apt  to  occur. 
Haemoptysis  indicates  a  wound  of  the  lung.  In  examin- 
ing chest-wounds,  feel  with  a  finger,  not  with  a  probe.  In 
wounds  of  the  pleura,  cleanse,  stitch  the  pleura  with  catgut 
or  fine  silk,  suture  the  skin,  dress  with  gauze,  and  immo- 
bilize the  chest.  Wounds  of  the  lung  demand  absolute  rest. 
Always  arrest  hemorrhage.  In  haemothorax,  if  the  effusion 
causes  intense  dyspnoea,  turn  out  the  clots  and  drain.  If 
emphysema  of  the  chest-walls  is  moderate,  strapping  or  a 
bandage  will  control  it ;  if  it  is  great,  make  multiple  punc- 
tures and  then  apply  pressure.  In  hernia  of  the  lung,  try  to 
restore  the  protrusion,  but  if  restoration  is  impossible  or  if 
gangrene  seems  highly  probable,  ligate  the  base  with  silk 
and  cut  away  the  mass.  If  foreign  bodies  in  the  thorax  can 
be  felt,  remove  them  ;  if  they  cannot  be  felt,  do  not  conduct 
a  prolonged  search,  but  leave  them  to  Nature. 

Paracentesis  Thoracis. — The  trocar  must  not  be  used 
except  in  an  emergency ;  the  aspirator  (Fig.  96)  is  greatly 
to  be  preferred.  The  aspirator  evacuates  the  fluid,  and,  as 
air  does  not  enter,  the  lung  expands  and  infection  does  not 
occur.  The  skin,  the  instruments,  and  the  surgeon's  hands 
must  be  asepticized.     Give  the  patient  a  little  whiskey,  and, 


SURGERY  OF   THE   RESPIRATORY  ORGANS.  595 

unless  he  is  very  weak,  make  him  sit  up  in  bed.  The  arm 
hangs  by  the  side,  and  the  surgeon  introduces  the  needle 
in  the  fifth  interspace,  just  in  fi-ont  of  the  angle  of  the 
scapula.  The  surgeon  marks  the  upper  border  of  the 
sixth  rib  with  the  index  finger,  and  plunges  in  the  needle 
just  above  the  finger,  thus  avoiding  the  intercostal  artery, 
which  lies  along  the  lower  border  of  the  rib  above.  Always 
guard  the  needle  with  a  finger  to  prev^ent  its  going  in  too 
far.  After  withdrawing  the  needle,  place  iodoform  collodion 
over  the  opening  in  the  chest.  When  the  fluid  is  purulent, 
tapping  rarely  proves  curative  except  in  the  empyemas  which 
follow  pneumonia  in  children.  In  pleuritic  effusion,  if  the 
lungs  will  not  expand  after  tappings,  perform  thoracot- 
omy. 

Thoracotomy  is  an  incision  into  the  cavity  of  an  empyema. 
The  instruments  required  are  a  scalpel,  a  grooved  dissector, 
forceps  (haemostatic  and  dissecting),  scissors,  a  dry  dissector, 
retractors,  bone-instruments  (in  case  rib-excision  is  required), 
drainage-tubes,  and  needles.  Chloroform  is  given  the  pa- 
tient, who  lies  supine  at  the  edge  of  the 
table,  with  the  arm  elevated  to  a  right 
angle  with  the  body.  Make  an  incision 
about  three  inches  in  length  along  the 
upper  border  of  the  lower  rib  bounding 
the  space  it  is  proposed  to  penetrate. 
This  space  is  either  the  sixth  or  the  sev- 
enth, and  the  desired  site  is  in  front  of 
the  posterior  axillary  fold.  Incise  the  fig.  isg.-Resection  of 
skin,  divide  the  intercostal  muscles  near  Rib  (Esmarch and  Kowai- 
the  rib,  push,  a  grooved  director  through 
the  pleura,  and  enlarge  the  opening  by  means  of  forceps 
and  the  finger.  The  finger  removes  all  masses  of  tuber- 
cular material  or  aplastic  lymph  within  reach.  Against 
washing  the  cavity  at  once  on  operation  is  the  great  author- 


596  A   MANUAL    OF  SURGERY. 

ity  of  Treves,  but  many  able  surgeons  advocate  immediate 
irrigation.  In  some  cases  a  counter-opening  is  made  by 
cutting  down  upon  the  long  probe  which  is  pushed  against 
the  chest-wall  after  being  introduced  through  the  incision ; 
in  other  cases  it  is  necessary  to  resect  a  rib  (p.  499;  Fig. 
139).  A  short  drainage-tube  is  introduced  and  stitched 
in  place.  U  a  counter-opening  has  been  made,  introduce 
another  short  tube,  but  do  not  pull  a  tube  through  both 
openings.  Arrest  bleeding,  suture  the  skin,  dust  with  iodo- 
form, dress  with  gauze,  wood-wool,  and  a  binder,  and  have 
the  dressings  changed  as  soon  as  they  become  soaked  at 
one  point.  After  a  day  or  so  has  passed,  wash  out  the  cavity 
once  every  twenty-four  hours.  Use  a  fountain-syringe.  Irri- 
gate first  with  warm  diluted  peroxide  of  hydrogen,  and  then 
with  hot  corrosive-sublimate  solution  (i  :  looo)  or  with  a  hot 
solution  of  tincture  of  iodine  (i  :  lOOO). 

Thoracoplasty  (Estlander's  operation)  is  employed  in  old 
cases  of  empyema  in  which  drainage  has  failed,  and  in  cases 
with  retracted  chest-walls,  collapsed  lungs,  thickened  pleura, 
and  cavities  whose  rigid  walls  will  not  collapse.  This  opera- 
tion causes  the  obliteration  of  the  cavity  by  collapsing  that 
portion  of  the  chest-wall  overlying  it.  The  cavity  is  in  the 
upper  or  central  part  of  the  pleural  space  (Treves).  The 
instruments  required  are  the  same  as  those  for  resection 
of  a  rib.  The  position  is  the  same  as  that  for  rib-resec- 
tion. The  length  of  the  incision  depends  on  the  size  of 
the  cavity.  The  surgeon  usually  removes  portions  of  the 
second,  third,  fourth,  fifth,  sixth,  and  seventh  ribs.  Make  a 
transverse  incision  along  the  centre  of  an  intercostal  space, 
and  through  this  incision  remove  the  ribs  above  and  below 
by  the  method  set  forth  on  page  499  (the  removal  of  six 
ribs  will  require  three  incisions).  Always  take  away  the 
periosteum.  Treves  recommends  that  the  cavity  be  at  once 
washed  out  with  corrosive  sublimate  (i  :  lOOo) ;  that,  if  small, 


DISEASES  AND  INJURIES   OF  DIGESTIVE    TRACT.       597 

it  be  packed  with  iodoform  gauze  and  allowed  to  granulate ; 
that,  if  large,  it  be  drained  by  a  large  tube,  the  skin  being 
sutured  by  silkworm  gut. 


XXV.  DISEASES  AND  INJURIES  OF  THE  DIGES- 
TIVE TRACT. 

Diseases  of  the  Mouth,  Tong-ue,  and  CEsophagus : 
Hare-lip  and  Cleft  Palate. — Hare-lip  is  a  congenital  cleft 
in  the  upper  lip.  Cleft  palate  is  a  congenital  fissure  in  the 
soft  palate  or  in  both  the  hard  and  soft  palates.  In  hare-lip 
the  cleft  is  usually  complete,  through  the  entire  lip  into  the 
nostril,  but  in  rare  cases  it  may  only  show  as  a  furrow  in  the 
mucous  edge  or  as  a  split  from  the  nostril  partly  into  the 
lips.  In  double  hare-lip  the  central  portion  of  the  lip  is 
often  adherent  to  the  tip  of  the  nose  (Bowlby).  Median 
hare-lip  is  exceedingly  rare.  In  cleft  palate  the  septum  of 
the  nose  is  usually  adherent  to  the  palatine  process  opposite 
to  the  side  upon  which  the  fissure  exists.  In  those  rare 
cases  of  cleft  palate  double  in  front  the  nasal  septum  is 
attached  only  to  the  premaxillary  bone,  and  the  premaxil- 
lary  bone  is  not  attached  at  all  to  the  superior  maxillae.  In 
hare-lip  there  is  often  a  cleft  in  the  alveolus,  and  almost 
always  flattening  of  the  corresponding  side  of  the  nose. 
Hare-lip  is  often  associated  with  cleft  palate,  talipes,  and 
other  deformities.  It  is  a  great  deformity,  and  interferes 
with  suckling,  swallowing,  and  articulation. 

Operation  for  hare-lip  should  be  performed  between  the 
third  and  sixth  months  of  life  in  a  child  in  good  health,  free 
from  stomach  trouble,  cough,  or  coryza,  but  operation  is  not 
advisable  in  the  early  weeks  of  life.  Always,  if  possible, 
operate  before  dentition  begins  (seventh  month).  If  the 
child  is  in  poor  health,  postpone  the  operation  until  restora- 
tion has  so  far  advanced  as  to  render  operation  safe.     If  a 


598  A   MANUAL    OF  SURGERY. 

cleft  exists  in  the  palate,  operate  first  upon  the  lip,  because 
the  pressure  of  the  parts  after  the  edges  of  the  gap  are 
approximated  aids  in  the  closure  of  the  bony  cleft.  Cleft 
palate  interferes  with  suckling,  deglutition,  mastication,  and 
articulation.  In  severe  cases  the  food  passes  into  the  nose 
and  excites  inflammation.  Loss  of  control  of  the  palate- 
muscles  always  exists,  and  liquids  and  solids  are  liable  to 
pass  into  the  windpipe.  Clefts  in  .the  hard  palate  should  not 
be  operated  on  until  the  tenth  or  twelfth  year  unless  the 
child  is  unable  to  take  sufficient  nourishment.  In  most 
cases  the  passage  of  food  and  drink  into  the  nose  can 
largely  be  prevented  by  the  use  of  a  diaphragm.  The  patient 
at  the  period  of  operation  should  be  well  and  free  from 
cough  (the  elder  Gross). 

Operation  for  Hare-lip. — The  instruments  required  are 
a  tenotome,  hare-lip  clamps,  toothed  forceps,  haemostatic 
forceps,  scissors  curved  on  the  flat  and  pointed,  straight 
blunt-pointed  scissors,  needles  (straight  and  curved),  silk- 
worm-gut and  silk  sutures,  a  mouth-gag 
and  tongue-forceps,  a  needle-holder,  and 
sequestrum  forceps,  each  blade  pro- 
tected by  a  rubber  tube.  Wrap  the  child 
in  a  sheet;  place  it  supine;  raise  the 
head   and   rest  it  upon  a  sand   pillow. 

"b  ^T The  surgeon  stands  to  the  right-hand 

Fig.  140.— Operation  for    sidc.    Ethcr  or  chloroform  is  givcu.    For 
^^""^'''P-  single  hare-lip,  separate  with  the  scissors 

the  upper  lip  from  the  bone  on  each  side  of  the  cleft  until 
approximation  of  the  cleft  can  be  effected  without  tension. 
If  the  maxillary  bone  of  one  side  projects  more  than  its 
fellow,  grasp  it  with  sequestrum  forceps  and  bend  it  back 
(Jacobson  and  Treves).  Put  a  compressor  in  each  angle  of 
the  mouth.  Grasp  the  lower  angle  of  one  flap  with  dissect- 
ing-forceps  and  pare  the  edge ;  carry  out  the  same  procedure 


DISEASES  AND   INJURIES    OF  DIGESTIVE    TRACT.        599 

upon  the  other  flap  (Fig.  140).  The  edges  are  approximated 
by  an  assistant,  and  silkworm-gut  sutures  are  passed  by 
means  of  a  straight  needle.  Each  suture  goes  down  to  the 
mucous  membrane.  The  first  suture  is  passed  through  the 
middle  of  the  lip,  one-third  of  an  inch  from  the  cleft.  Three 
or  four  main  sutures  are  passed  through  the  thickness  of 
the  lip,  and  are  tied  and  cut  off  Two  or  three  fine  silk 
sutures  are  passed  by  curved  needles  through  the  vermilion 
border  of  the  lip  and  its  mucous  membrane,  and  are  tied 
and  cut  off  A  small  piece  of  gauze  is  placed  over  the  lip 
and  is  held  in  place  by  straps  of  rubber  plaster.  About  the 
sixth  day  one-half  the  sutures  are  taken  out,  and  on  the 
eighth  or  ninth  day  the  remaining  ones  are  removed.  Hare- 
lip pins  are  rarely  used  at  the  present  time,  and  are  not 
needed  if  the  lip  is  well  separated  from  the  bone. 

In   double   hare-lip  the   operation  is  similar  to  that   for 
single  hare-lip.     If  the  intervening  piece  is  vertical  and  is 
covered  with  healthy  skin,  complete  each  operation  as  for 
single  hare-lip,  closing  both   fissures 
at    once    in  a  strong,    healthy   child,  ^^   ^^^^ 

closing    them    at    intervals    of   three  i^^^^ffis^ 

weeks  in  one   not   so  lusty.     Excise  JU {       jV\ 

the    septum    if  it   is   deformed.     The        '^^^^^X^^^ 
premaxillary  bone  should  in  most  in-  '  /^^^^^^ 

stances  be  removed,  the  skin  over  it  '^^^^^ 

beino-  preserved.    Sir.  \Vm.  Ferq-usson      ^  t   •  •     <•   t^   ui 

«=>   i  ^  tiG.  141. — Incisions  for  Uouble 

was    accustomed  to  incise  the   mucous      Hare-Up  (Esmarch  and  Kowal- 

zisr). 

membrane   and    shell   out  this   bone. 

The  premaxillary  bone  can  be  forced  back  into  line,  being 
held,  if  necessary,  by  catgut  suture  of  the  periosteum  ;  but 
if  saved  it  is  liable  to  necrose  and  its  teeth  soon  decay. 
Figure   141   shows  incisions  for  double  hare-lip. 

Operation  for  Cleft  Palate. — Early   operations    are   veiy 
dangerous-  in  bony  clefts,  and   during  the   early  years   of 


6oO  A   MANUAL    OF  SURGE J^Y. 

growth  the  clefts  diminish  in  size.  Bony  clefts  should  be 
operated  upon  about  the  twelfth  year.  Clefts  of  the  soft 
palate  only  may  be  operated  upon  in  the  third  year  (Thomas 
Smith).  For  closure  of  tJie  soft  palate  {staphylorrhapJiy) 
Treves  says  the  following  instruments  are  essential :  Two 
sharp-pointed  tenotomes,  a  blunt-pointed  tenotome,  a  rect- 
angular knife,  two  pairs  of  long  forceps  (one  with  tenaculum 
points,  one  serrated),  a  fine  hook,  a  pair  of  sharp-pointed 
curved  scissors,  scissors  curved  on  the  flat,  periosteum-ele- 
vators, two  long-handled  needles  with  eyes  at  their  points, 
a  suture-catcher,  a  tubular  needle  for  wire  sutures,  haemo- 
static forceps,  Whitehead's  gag  and  retractors,  silver  wire, 
silkworm  gut,  and  .sponge-holders ;  also  an  electric  forehead 
light.  The  patient's  body  is  raised,  and  his  head  is  elevated 
and  rested  upon  a  sand-bag.  A  better  position  would  be 
that  of  Trendelenburg,  thus  avoiding  the  blood  trickling 
into  the  windpipe.  Chloroform  is  given.  The  gag  is  intro- 
duced ;  the  edges  of  the  fissure  are  pared  with  the  tenotome; 
the  sutures  are  introduced  from  below  upward,  silkworm  gut 
being  used  for  the  uvula  and  lower  part  of  the  velum,  silver 
wire  for  the  remainder  of  the  cleft;  each  suture,  as  it  is 
passed,  is  tied  or  twisted,  but  is  not  cut  until  the  next  suture 
is  inserted,  thus  serving  as  a  handle.  If  there  is  too  much 
tension  to  allow  of  the  sutures  being  tied  as  they  are  inserted, 
all  the  sutures  are  passed  and  loosely  twisted  ;  a  longitudinal 
incision  is  made  upon  each  side,  internal  to  the  hamular 
process,  the  mucous  membrane  being  cut  with  the  sharp  teno- 
tome, the  deeper  structures  being  divided  with  a  blunt  teno- 
tome;  the  sutures  are  tied  or  twisted  and  cut  (Fig.  142).  In 
Fergiisson' s  operation  for  clefts  in  the  hard  palate  (iiranoplasty) 
the  mucous  edges  are  pared  and  the  sutures  inserted  but  not 
tied.  Make  an  incision  upon  each  side  down  to  the  bone, 
the  incision  being  midway  between  the  cleft  and  the  alveolus. 
Divide  the  bone  on  each  side,  by  means  of  a  chisel,  to  the 


DISEASES  AND   INJURIES   OF  DIGESTIVE    TRACT.       6oi 

full  length  of  the  incision,  and,  using  the  chisel  as  a  lever, 
force  each  half  of  the  bone  toward  the  gap.  Tie  the  sutures, 
and  plug  each  lateral  incision  with  a  piece  of  iodoform  gauze 
(Fig.  143).  After  the  operation  for  cleft  palate,  put  the  pa- 
tient to  bed  for  one  week  ;  forbid  talking  ;  give  fluid  or  semi- 
solid food  for  three  weeks  at  intervals  of  two  or  three  hours ; 


Fig.   142. — Staphylorrhaphy  (Esmarch   and  Fig.    143. — Uranoplasty    (Esmarch   and 

Kowalzig).  Kowalzig). 

wash  out  the  mouth  very  often  (always  after  eating)  with  a 
carbolic  solution  (i  :  lOo)  or  a  solution  of  boracic  acid  and 
listerine.     Sutures  are  removed  in  from  two  to  three  weeks. 

Tongue-tie  is  a  congenital  shortness  of  the  fraenum.  The 
tongue  cannot  be  protruded  beyond  the  incisor  teeth.  Swal- 
lowing is  interfered  with,  and  later  in  life  articulation  is 
impeded.  To  treat  tongue-tie,  tear  up  the  fraenum  with  the 
thumb-nail.  If  this  fails,  catch  the  fraenum  in  the  slit  in  the 
handle  of  a  grooved  director,  push  the  director  toward  the 
floor  of  the  mouth,  and  divide  the  fraenum  with  scissors 
curved  on  the  flat  and  pointed  toward  the  director. 

Ranula  is  a  dilatation  of  one  of  the  ducts  of  the  mucous 
glands  of  Nuhn  and  Blandin.  These  glands  lie  on  each  side 
of  the  fraenum  of  the  tongue.  It  was  long  thought  that  a 
ranula  arose  from  obstruction  in  the  duct  of  the  sublingual 
gland.  A  ranula  appears  upon  the  floor  of  the  mouth  on 
one  side  and  pushes  the  tongue  toward  the  opposite  side. 
The  contents  of  a  ranula  resemble  mucus  or  saliva.     The 


6o2 


A   MANUAL    OF  SURGERY. 


treatment  of  ranula  is  by  the  seton ;  by  excision  of  a  por- 
tion of  the  cyst-wall  and  cauterization  of  the  interior  with 
pure  carboHc  acid  or  with  15  minims  of  a  solution  consisting 
of  10  parts  of  tincture  of  iodine,  10  parts  of  water,  and  I  part 
of  iodide  of  potassium  ;  or  by  cutting  a  flap  from  the  cyst-wall 
and  stitching  it  aside  so  as  to  keep  a  permanent  opening. 

Excision  of  Tongue  (Kocher's  Method). — Kocher  used 
to  employ  a  preliminary  tracheotomy  in  tongue-excision, 
but  the  Trendelenburg  chair  renders  this  procedure  unneces- 
sary so  far  as  hemorrhage  is  concerned.  Always  clean  the 
mouth  well.  The  instruments  required  are  a  scalpel,  retrac- 
tors, a  dry  dissector,  haemostatic 
and  dissecting-forceps,  a  tenacu- 
lum, aneurysm-needle,  tenaculum 
forceps,  needles,  sutures,  and  scis- 
sors. In  this  operation  the  pa- 
tient is  placed  in  the  Trendelen- 
burg position,  the  surgeon  being 
on  the  affected  side.  Chloroform 
is  given.  An  incision  is  made 
from  behind  the  lobe  of  the  ear, 
along  the  anterior  edge  of  the 
sterno-cleido-mastoid  to  about 
the  middle  of  the  margin  of  this  muscle.  From  this  point 
the  incision  is  carried  to  the  hyoid  bone  and  then  to  the 
symphysis  menti,  along  the  anterior  belly  of  the  digastric 
♦  muscle  (Fig.  144).  The  flap  is  dissected  and  turned  up; 
the  facial  and  lingual  arteries  are  ligated  ;  "  the  submaxil- 
lary fossa  is  evacuated  "  (Treves)  ;  the  sublingual  and  sub- 
maxillary glands  are  removed;  the  mylo-hyoid  muscle  is 
divided ;  the  mucous  membrane  is  incised  close  to  the 
jaw,  and  the  tongue,  caught  with  tenaculum  forceps,  is 
drawn  through  the  opening.  Split  the  tongue  in  the  middle 
with   scissors,  and   remove   the    near   half     If  the   whole 


Fig.   144. — Excision  of  Tongue   (Es- 
march  and  Kowalzig). 


DISEASES  AND   INJURIES   OF  DIGESTIVE    TRACT.       603 

tongue  requires  removal,  perform  a  set  ligation  of  the  lingual 
artery  of  the  opposite  side.  Arrest  bleeding.  Some  sur- 
geons stitch  the  mucous  membrane  of  the  stump  to  the 
mucous  membrane  of  the  floor  of  the  mouth  ;  others  em- 
ploy no  sutures.  Kocher  does  not  suture  his  skin-wound ; 
other  surgeons  do,  and  employ  drainage-tubes.  Keen  ad- 
vises closing  the  floor  of  the  mouth  if  possible.  Some  hours 
after  the  operation,  when  oozing  has  ceased,  dust  the  mouth- 
wound  with  iodoform.  The  patient,  as  soon  as  possible, 
is  propped  up  in  bed,  and  he  must  not  swallow  the  dis- 
charges if  it  can  be  avoided.  The  mouth,  every  half  hour, 
is  sprayed  out  with  peroxide  of  hydrogen  and  washed  with 
a  carbolic  solution  (i  :  60) ;  every  three  hours,  after  a  washing, 
the  floor  of  the  mouth  and  the  stump  are  dried  with  absorb- 
ent cotton  and  dusted  with  iodoform.  For  twenty-four  hours 
after  the  operation  nothing  is  given  by  the  mouth  except  a 
little  cracked  ice,  the  patient  being  fed  per  rectum.  At  the 
end  of  twenty-four  or  forty-eight  hours  some  liquid  food  is 
given  by  a  feeding-cup.  The  patient  will  soon  learn  to  swal- 
low, but  if  he  cannot  swallow,  feed  him  with  a  tube.  .  Treves, 
in  his  clear  and  positive  directions  for  after-treatment,  states 
that  nutrient  enemata  are  to  be  continued  until  sufficient 
nourishment  is  taken  by  the  mouth ;  that  the  mouth  should 
be  flushed  out  by  irrigation,  and  must  be  washed  imme- 
diately after  taking  food  ;  that  morphia  is  to  be  avoided ; 
and  that  the  patient  can  usually  leave  the  hospital  in  from 
seven  to  ten  days. 

Stricture  of  the  CEsophag-us. — Fibrous  or  cicatricial 
stricture  is  due  to  a  wound,  to  swallowing  a  corrosive  sub- 
stance, or  to  syphilis.  It  is  commonest  in  the  young,  and 
is  apt  to  be  situated  opposite  the  cricoid  cartilage.  Jllalig- 
nant  or  cancerous  stricture,  which  arises  in  those  beyond 
middle  life,  is  more  common  in  men  than  in  women.  It  is 
usually  due-  to  epithelioma,  and  its  most  usual  site  is  on  a 


6o4 


A   MANUAL    OF  SURGERY. 


level  with  the  cricoid  cartilage.  It  is  invariably  fatal,  usually 
by  means  of  septic  pneumonia  or  starvation.  Spasmodic  or 
hysterical  stricture,  which  is  commonest  in  women,  is  asso- 
ciated with  the  stigmata  of  hysteria,  and  especially  with 
globus  (a  sense  as  of  a  ball  rising  in  the  throat) ;  a  bougie 
held  against  it  is  only  temporarily  obstructed.  The  contrac- 
tion arises  suddenly, 
and  one  passage  of  a 
bougie  often  causes  it 
to  disappear. 

SyinptoDis  a7id 
Treatment  of  Organic 
Stricture.  —  Difficulty 
of  swallowing,  emaci- 
ation, regurgitation  of 
food  which  was  appar- 
ently swallowed  (be- 
cause of  dilatation 
above  the  stricture). 
Auscultation  as  fluid 
is  being  swallowed 
will  locate  the  ob- 
struction. The  bougie 
makes  the  diagnosis 
(Fig.  145,  e).  In  fi- 
brous stricture,  feed 
the  patient  on  liquid 
food  and  on  food  cut  up  into  very  small  pieces.  Pass  a 
bougie  every  day,  gradually  increasing  the  size.  In  cancer- 
ous stricture  bougies  are  dangerous ;  if  they  are  passed,  it 
must  be  very  gently.  The  passage  daily  of  a  soft-rubber 
catheter  maintains  an  open  way.  Feed  upon  liquids,  through 
a  tube  if  necessary,  and  when  this  becomes  difficult  or  impos- 
sible, perform  gastrostomy.     Symonds  advocates  permanent 


Fig.  145. — operating  Instruments:  a,  b,  forceps;  c 
horsehair  probang  ;  d,  coin-catcher;  E,  CEsophageal  bou' 
gie   (Esmarch  and  Kowalzig). 


DISEASES  AND   INJURIES   OF  DIGESTIVE    TRACT.       605 

tubage  of  strictures.  The  younger  Gross  advocated  a  course 
of  iodide  of  potassium  in  stricture,  because  of  the  possibiHty 
of  syphiHs.  The  operation  of  oesophagostomy  has  been 
undertaken,  but  with  poor  success.  Excision  of  the  dis- 
eased portion  of  the  oesophagus  has  been  practised. 

Foreign  Bodies  in  the  CEsophagus. — A  large  foreign 
body  in  the  oesophagus  is  apt  to  be  arrested  at  the  smallest 
part  of  the  tube,  opposite  the  cricoid  cartilage.  Foreign 
bodies  are  frequently  caught  where  the  gullet  is  crossed 
by  the  left  bronchus  and  also  where  it  passes  through  the 
diaphragm.  Small  and  sharp  bodies  may  lodge  any- 
where. 

Symptoms  and  Treatment, — If  the  body  is  large,  there  will 
be  pain  and  difficulty  in  swallowing,  and,  in  some  cases, 
dyspnoea.  If  the  body  is  sharp,  there  will  be  hemorrhage 
and  severe  pain.  A  patient  may  grow  accustomed  to  a  foreign 
body,  and  cease  to  notice  it ;  but,  on  the  contrary,  the  for- 
eign body  may  produce  inflammation,  and  even  may  ulcerate 
into  the  windpipe,  the  pleura,  the  pericardium,  or  the  aorta. 
Even  after  a  foreign  body  has  been  removed  by  swallowing 
or  otherwise,  a  sensation  is  apt  to  remain  as  if  it  were  still 
lodged.  The  diagnosis  in  children  or  lunatics  is  made  by 
the  detection  of  the  body  by  external  manipulation  and  by 
feeling  it  with  an  oesophageal  bougie.  A  round  smooth 
body  is  grasped  with  forceps  and  pulled  out,  or,  if  this  is 
impossible,  it  is  pushed  down  with  a  probang.  Sharp 
bodies  are  removed  with  a  horsehair  probang  (Fig.  145,  c). 
Coins  are  removed  with  a  coin-catcher  (Fig.  145,  d).  Various 
forceps  are  employed  (Fig.  145,  A,  b).  Vomiting  sometimes 
displaces  a  foreign  body.  In  rare  instances  oesophagotomy 
is  demanded,  the  cut  being  made  on  the  left  side,  between 
the  trachea  and  the  larynx  in  front  and  the  carotid  sheath 
behind,  the  centre  of  the  incision  being  opposite  the  cricoid 
cartilage.     After    removing   the    foreign    body,    suture    the 


6o6  A   MANUAL    OF  SURGERY. 

oesophagus   with    catgut   and    feed   the   patient  through   a 
tube  for  one  week. 


XXVI.    DISEASES    AND    INJURIES    OF    THE 

ABDOMEN. 

Contusion  of  the  Abdominal  "Wall. — In  some  cases  of 
contusion  of  the  abdominal  wall  only  the  parietes  are  con- 
tused ;  in  other  cases  the  viscera  or  the  abdominal  tissues 
are  injured.  In  simple  cittancous  contusion  there  is  con- 
siderable shock  if  the  injury  is  severe;  there  is  pain,  in- 
creased by  respiration,  and  ecchymosis  soon  appears.  In 
treating  simple  contusion,  place  the  patient  at  rest  in  a 
supine  position ;  obtain  reaction  from  the  shock ;  give 
morphia  for  pain;  place  an  ice-bag  over  the  injury  from 
time  to  time,  and  in  the  intervals  of  its  application  use  lead- 
water  and  laudanum  locally.  If  much  blood  is  extravasated, 
aspirate  and  apply  a  binder.  After  twenty-four  hours  apply 
intermittent  heat  by  poultice,  employ  an  ointment  of  ichthyol, 
and  move  the  bowels,  if  necessary,  by  salines. 

Muscular  Rupture  from  Contusion. — In  this  injury  there 
are  severe  shock  and  pain  (increased  by  respiration  and 
movement).  Separation  between  the  fibres  of  the  muscle 
is  distinct  at  first,  but  it  is  soon  masked  by  effusion  of 
blood.  Such  injuries  may  cause  death,  or  they  may  lead 
to  hernia. 

The  treatment  is  the  same  as  for  simple  contusion.  Always 
apply  a  binder.  A  hernia  is  returned  and  a  compress  is 
applied  over  the  opening  through  which  it  emerged.  If 
strangulation  occurs,  operate  at   once. 

Rupture  of  the  Stomach  without  External  Wound. — 
The  symptoms  of  this  injury  are — excessive  shock;  pain 
over  the  entire  abdomen,  especially  over  the  epigastric 
region;  and  vomiting  of  blood  if  the  mucous  membrane  is 


DISEASES  AND   INJURIES   OF   THE  ABDOMEN.       607 

torn.  After  incomplete  rupture  local  peritonitis  is  frequent; 
in  complete  rupture  the  escape  of  food  into  the  peritoneal 
cavity  causes  septic  peritonitis.  To  diagnosticate  between 
complete  and  incomplete  ruptures,  endeavor  to  distend  the 
viscus  with  hydrogen  gas  :  in  incomplete  rupture  the  contour 
of  the  dilated  stomach  can  be  made  out  upon  the  surface ; 
in  complete  rupture  the  viscus  cannot  be  distended  and  the 
gas  passes  into  the  peritoneal  cavity,  producing  the  physical 
signs  of  tympanites  (Senn).  The  treatment  in  complete  rup- 
ture is  as  follows :  React  from  shock  and  at  once  open 
the  abdomen ;  if  the  rent  is  not  visible,  find  it  by  inflating 
with  hydrogen ;  flush  out  the  stomach  and  the  peritoneal 
cavity ;  sew  up  the  stomach-wound  with  a  double  row  of 
silk  sutures,  the  first  row  being  buried  and  including  the 
muscular  coat  and  mucous  coat,  the  second  row  being  Lem- 
bert  sutures ;  drain ;  close  the  wound  in  the  parietes  with 
silkworm  gut;  feed  b\-  the  rectum  for  four  days,  and  then 
begin  the  administration  of  a  very  little  food  by  the  mouth. 
In  incomplete  rupture  the  danger  is  perforation.  The  patient 
is  put  to  bed,  is  reacted,  is  fed  by  the  rectum  for  several 
days,  and  morphia  is  given  hypodermatically. 

Rupture  of  the  Intestine  'without  External  Wound. — 
The  symptoms  of  this  injury  are  profound  shock,  tympani- 
tes, and  pain,  rapidly  followed  by  peritonitis.  Vomiting 
comes  on  soon  after  the  accident,  the  vomited  matters  being 
at  first  bloody  and  then  stercoraceous.  The  respiration  is 
thoracic,  the  tongue  is  dry,  and  great  thirst  exists.  The 
pulse,  which  is  slow  at  first,  becomes  small  and  rapid.  A 
high-tension  pulse  goes  with  tympanites,  because  the  disten- 
tion of  the  bowel  greatly  decreases  the  amount  of  blood  in 
its  coats,  and  thus  increases  the  amount  of  blood  in  the  rest 
of  the  system.  Any  portion  of  the  intestine  may  rupture,  but 
the  ileum  is  most  liable  to  this  accident.  Blood  in  the  stools 
rarely  appears  early  enough  to  be  of  diagnostic  value.     The 


6o8  A   MANUAL    OF  SURGERY. 

escape  of  gas  into  the  peritoneal  cavity  may  cause  disappear- 
ance of  normal  liver-dulness.  By  anaesthetizing  the  patient 
hydrogen  gas  insufflated  into  the  rectum  will  come  from  the 
mouth  if  there  is  no  perforation  in  the  stomach  or  the  intes- 
tine ;  if  a  perforation  exists,  tympanites  is  much  increased. 
To  apply  rectal  insufflation  of  hydrogen,  generate  the  gas  in 
a  bottle  by  means  of  zinc  and  sulphuric  acid,  catch  the  gas 
in  a  large  rubber  bag,  and  attach  the  tube  from  the  gas 
reservoir  to  a  tip  which  is  inserted  in  the  rectum.  Give  the 
patient  ether  to  relax  the  abdominal  muscles,  direct  an 
assistant  to  press  the  anal  margins  against  the  rectal  tip,  and 
when  the  patient  is  unconscious  turn  on  the  stopcock  and 
press  upon  the  reservoir  (Senn). 

Ti'eatiiient. — Give  stimulants  by  the  rectum,  and  a  hypo- 
dermatic injection  of  morphia  and  atropia ;  asepticize  and 
anaesthetize.  Perform  a  laparotomy ;  check  hemorrhage ; 
find  the  rent,  and  close  it  by  Lembert  sutures  if  possible. 
It  may  be  necessary  to  perform  an  end-to-end  approxima- 
tion or  an  intestinal  anastomosis.  Flush  out  the  abdominal 
cavity  with  cooled  boiled  water.  The  hydrogen-gas  test  will 
discover  perforations. 

"  In  abdominal  operations  it  is  frequently  imperatively 
necessary  that  the  large  intestine  be  recognized  with  cer- 
tainty or  the  small  bowel  be  positively  identified.  The  size 
of  the  tube  will  not  always  aid  in  this  recognition,  as  a  small 
intestine  may  be  distended  enormously  and  a  large  intestine 
may  be  contracted  to  the  size  of  a  finger  because  of  obstruc- 
tion above.  The  longitudinal  muscular  fibres  of  the  large 
bowel  are  accentuated  in  three  portions ;  these  accentuations 
constitute  the  three  longitudinal  bands  which  begin  at  the 
caecum  and  terminate  at  the  end  of  the  sigmoid  flexure  of 
the  colon.  Each  band  is  composed  of  a  number  of  shorter 
bands,  the  shortness  of  these  constituent  bands  permitting 
the  sacculation  of  the  large  intestine.     Longitudinal  bands 


DISEASES  AND   INJURIES   OF   THE   ABDOMEN.       609 

and  sacculation  are  not  met  with  in  the  small  gut,  their  pres- 
ence or  absence  being  a  means  of  identification  in  many- 
cases  ;  but  when  the  colon  is  much  distended  the  bands 
cannot  be  seen  distinctly  and  the  sacculation  disappears. 
From,  the  large  intestine  only  spring  the  appendices  epiplo- 
icae  (small  overgrowths  of  fat  in  pouches  of  peritoneum), 
but  they  are  sometimes  not  well  marked  except  upon  the 
transverse  colon,  and  when  emaciation  exists  they  may 
almost  entirely  disappear.  The  relatively  fixed  position  of 
the  large  intestine  and  the  free  mobility  of  the  small  bowel 
are  important  points  of  distinction.  The  foregoing  indicates 
that  it  is  not  always  easy  to  distinguish  between  colon  and 
small  gut,  and  that,  according  to  old  rules,  it  may  often  be 
necessary  to  make  large  incisions,  to  see  as  well  as  feel,  and  to 
handle  a  large  extent  of  the  bowel.  Any  scrap  of  knowledge 
that  will  shorten  an  abdominal  operation,  that  will  permit  of 
as  certain  work  through  a  smaller  incision,  and  that  will 
diminish  handling  of  intraperitoneal  structures,  tends  to  in- 
crease the  chances  of  recovery.  For  these  reasons  the  writer 
suggests  a  method  of  bowel-identification  which  rests  upon 
the  facts  that  each  bowel  has  a  posterior  attachment,  that  the 
origin  of  the  attachment  differs  according  to  the  bowel  it 
supports,  that  a  single  finger  can  detect  the  origin  of  the 
peritoneal  support  of  any  section  of  the  bowel,  and,  this 
origin  being  known,  the  portion  of  bowel  it  supports  is 
with  certainty  deducible.  In  an  exploratory  operation,  for 
instance,  the  finger  comes  in  contact  with  the  bowel :  to  de- 
termine whether  it  is  a  large  or  a  small  bowel,  note  first  if 
the  structure  is  movable  or  is  firmly  fixed  ;  next,  pass  the 
finger  over  the  bowel  and  let  it  find  its  way  posteriorly.  If 
dealing  with  a  small  bowel,  the  finger  will  reach  the  origin 
of  the  mesentery  between  the  left  side  of  the  second  lumbar 
vertebra  and  the  right  sacro-iliac  joint ;  if  dealing  with  the 
large  bowel,  the  finger  will  reach  the  origin  of  the  meso- 
39 


6lO  A    MANUAL    OF  SURGERY. 

colon,  or  the  point  where  the  colon  is  fixed  posteriorly  and 
to  the  side."  ^ 

After  flushing  out  the  abdomen  a  drainage-tube  is  inserted 
and  the  wound  is  closed. 

"Wounds  of  the  Abdominal  Wall.  —  Non-penctrati)ig 
wounds  are  to  be  treated  on  general  principles.  Suture 
with  great  care  and  apply  external  support.  Ventral  hernia 
may  follow  a  large  wound. 

Penetrating  Wounds. — The  symptoms  of  penetrating  wounds 
of  the  abdominal  wall  are  usually  those  of  shock  and  hem- 
orrhage, and  later  of  septic  peritonitis.  Emphysema  is  apt 
to  occur.  Viscera  may  protrude.  In  an  incised  or  a 
lacerated  wound  some  of  the  contents  of  the  abdomen 
may  protrude.  If  protruding  viscera  are  uninjured,  they  are 
cleansed  with  cooled  boiled  water  and  returned  into  the 
abdomen,  the  wound  being  enlarged  if  necessary.  The  belly 
is  flushed  out  with  hot  sterilized  water  to  remove  blood-clots, 
a  drainage-tube  is  inserted,  the  peritoneum  is  sutured  with 
catgut,  and  the  muscles  and  integument  are  approximated 
with  silkworm  gut.  If  the  viscera  are  injured,  treat  them 
appropriately.  In  punctured  and  in  gunshot  wounds,  when 
the  intestine  has  been  perforated,  rectal  insufflation  of  hydro- 
gen will  often  disclose  the  fact,  but  evisceration  may  be  neces- 
sary. Always  arrest  bleeding.  In  punctured  wounds  enlarge 
the  wound  of  entrance,  examine  for  injury  of  viscera,  close 
perforations  if  any  are  found,  flush  out  the  belly,  drain,  and 
close  the  wound.  In  gunshot  wounds  examine  for  a  wound 
of  exit ;  follow  the  track  of  entrance  by  means  of  a  knife  and 
a  grooved  director ;  open  the  peritoneum ;  arrest  hemor- 
rhage ;  look  for  perforations  and  close  them ;  examine 
viscera ;  search  for  the  ball,  but  not  long,  and  if  it  is  found, 
remove  it  ;  flush  out  the  belly  with  hot  sterilized  water ; 
dry  with  sponges ;  drain ;  and  close  the  wound.     In  some 

^  The  author,  in  Medical  News,  June  9,  1894. 


DISEASES  AND   INJURIES   OF   THE   ABDOMEN.       6ll 

cases  of  penetrating  wounds  of  the  abdomen  enterectomy 
will  be  required,  and  also  enterorrhaphy.  Irrigation  of  the 
cavity  is  only  required  when  the  contents  of  the  stomach  or 
the  bowel  have  escaped  or  when  a  considerable  hemorrhage 
has  taken  place.  The  surgeon  should  drain  when  the  con- 
tents of  the  stomach  or  the  intestines  have  escaped,  when 
hemorrhage  is  severe,  or  when  the  liver,  pancreas,  kidney,  or 
spleen  is  damaged.  Active  stimulation  and  artificial  heat  are 
needed  immediately  after  the  operation,  to  combat  shock. 
The  after-treatment  consists  of  rest,  opium  in  small  amounts 
to  arrest  peristaltic  action,  avoidance  of  food  by  the  stomach 
for  fort\--eight  hours,  and  the  administration  of  brandy  and 
water  from  time  to  time.  Feed  by  the  rectum  for  two  days. 
On  the  appearance  of  the  first  sign  of  peritonitis  forty-eight 
hours  or  more  after  the  operation,  give  a  saline  cathartic.  It 
will  not  do  to  purge  during  the  first  forty-eight  hours  after  the 
operation.  When  there  is  no  sign  of  peritonitis,  do  not  purge 
until  the  fourth  day.  After  forty-eight  hours  liquid  food  can 
usually  be  given  by  the  stomach.  Solid  food  may  be  given 
after  seven  or  eight  days,  but  the  patient  must  not  leave  his 
bed  until  the  wound  is  solidly  united,  because  of  the  danger 
of  ventral  hernia.    A  support  should  be  worn  for  a  long  time. 

Foreign  Bodies  in  the  Alimentary  Canal. — Most  foreign 
bodies  are  passed  with  the  feces.  A  purgative  should  never 
be  given  to  expedite  the  passage  of  a  foreign  body,  because 
increased  peristalsis  means  increased  danger  of  impaction  or 
of  perforation.  Endeavor  to  encrust  the  foreign  body,  and 
thus  lessen  the  danger  of  perforation,  by  feeding  with  bread 
and  milk  only  for  several  days,  and  at  the  eiid  of  this  period 
give  a  mild  laxative.  An  exclusive  diet  of  mush  or  of 
mashed  potatoes  has  been  suggested.  If  a  foreign  body 
lodges  in  the  stomach,  perform  a  gastrotomy. 

Cancer  of  the  Stomach. — Surgical  treatment  may  aim  at 
the   excision   of  the    growth,  or  may  seek  to  remove  the 


6l2  A   MANUAL    OF  SURGERY. 

mechanical  impediment  to  tlic  entrance  of  food  into,  or  the 
emergence  of  food  from,  the  stomach.  In  stricture  of  the 
cardiac  orifice  of  the  stomach  the  surgeon  usually  keeps  the 
passage  open  as  long  as  possible  by  the  frequent  passage  of 
a  tube,  and  through  this  tube  introduces  liquid  food.  Some- 
times a  small  tube  is  introduced  and  permanently  retained. 
If  a  tube  cannot  be  introduced,  gastrostomy  is  performed, 
and  through  this  artificial  opening  the  patient  is  fed  (p.  635). 
In  cancer  of  the  pylorus  limited  in  extent  and  without 
lymphatic  involvement,  pylorectomy  may  be  performed  ;  but 
in  cancer  which  has  widely  infiltrated  the  coats  of  the  stom- 
ach and  has  involved  the  lymphatic  glands,  gastro-enteros- 
tomy  is  performed  as  a  palliative  measure,  the  patient  during 
the  balance  of  his  life  subsisting  upon  liquid  or  semi-liquid 
foods  and  submitting  to  frequent  irrigation  of  the  stomach 
to  remove  food-residue.  In  cases  of  ineradicable  cancer  it 
is  usually  best  to  create  the  opium-habit. 

Cicatricial  stenosis  of  the  orifices  of  the  stomach  results 
from  the  healing  of  an  ulcer,  the  swallowing  of  a  corrosive 
substance,  or  a  traumatism  from  a  foreign  body.  Constric- 
tion of  the  cardiac  orifice  is  indicated  by  gradually  increasing 
difficulty  in  swallowing.  After  a  time  the  oesophagus  above 
the  stricture  dilates  or  pouches ;  the  fluid  food  passes  into 
the  stomach,  but  the  solid  food  lodges  in  the  oesophageal 
pouch  and  is  soon  regurgitated.  The  site  of  the  stricture  is 
located  by  a  bougie.  If  the  constriction  be  malignant,  the 
patient  will  be  found  to  be  beyond  middle  life,  a  tumor  may 
possibly  be  felt,  the  vomit  is  occasionally  blood)-,  and  emacia- 
tion is  rapid  and  decided.  If  the  constriction  be  cicatricial, 
the  history  will  exhibit  the  cause.  Constriction  of  the  pyloric 
orifice  causes  retention  of  food  and  dilatation  of  the  stomach. 
Dyspeptic  symptoms  will  be  found  to  have  been  long  present. 
A  tube  passed  into  the  stomach  permits  of  the  injection  of 
fluid  so  as  to  fill  the  stomach.     When  the  fluid  runs  out  it 


DISEASES  AND   LNJURIES   OF   THE  ABDOMEN.       613 

contains  portions  of  undigested  food  eaten  days  before,  and 
measurement  of  the  liquid  shows  that  the  capacity  of  the 
stomach  is  enormously  increased.  If  air  be  forced  through 
the  tube,  the  outHne  of  the  distended  stomach  is  at  once 
made  clear.  The  usual  method  of  distending  the  stomach 
is  by  a  Seidlitz  powder :  two  solutions  are  made ;  the  bicar- 
bonate solution  is  swallowed  at  once,  and  the  tartaric  solu- 
tion is  taken  afterward  in  small  amounts  at  a  time. 

Treatment. — Cardiac  stenosis  requires  dilatation  with 
boueies  and  the  maintenance  of  the  restored  calibre.  If 
this  dilatation  is  unsatisfactory,  perform  a  gastrotomy,  push 
a  small  bougie  from  the  mouth  into  the  stomach,  tie  a  string 
to  the  bougie,  draw  the  string  through  the  stricture,  use  the 
string  as  a  saw  to  cut  the  fibrous  bands,  pass  a  full-sized 
bougie,  close  the  wound  in  the  stomach,  and  maintain  the 
calibre  by  the  repeated  passage  of  dilating  instruments.  If 
no  instrument  can  be  passed  through  the  stricture,  perform 
a  gastrotomy,  introduce  an  instrument  from  below,  and  use 
Abbe's  string  saw.  If  no  instrument  can  be  passed  from 
below,  convert  the  gastrotomy  into  a  gastrostomy.  Pyloric 
stenosis  is  treated  by  a  gastrotomy  and  digital  divulsion  of 
the  stricture  (Loreta's  operation),  by  pyloroplasty  (Heineke- 
Mikulicz  operation),  or  by  gastro-enterostomy. 

Intestinal  Obstruction  (Ileus  or  Entero-stenosis). — Intes- 
tinal obstruction  is  a  condition  in  which  fecal  movement  is 
mechanically  impeded  or  prevented.  It  may  be  either  partial 
or  complete.  Acute  obstruction  is  due  to  a  sudden  narrowing 
or  occlusion  of  the  lumen  of  a  portion  of  the  intestine. 
Chronic  obstruction  is  due  to  a  gradual  narrowing  of  the 
lumen  of  a  portion  of  the  intestine,  and  it  may  at  any  time 
become  acute.  If  obstruction  to  circulation  in  the  wall  of 
the  bowel  occurs,  the  condition  becomes  one  of  strangula- 
tion.    Intestinal  obstructions  are  classified  ^  as  follows  : 

^  After  Treves,  in  Heath's  Dictionary. 


6 14  A   MANUAL    OF  SURGERY. 

1.  Stra7igiilation  by  bands  or  in  apertures,  the  commonest 
form,  is  due  to  peritoneal  adhesions,  but  the  band  may  come 
from  the  omentum.  Strangulation  may  take  place  by 
Meckel's  diverticulum,  a  structure  due  to  persistence  of  the 
vitelline  duct,  and  coming  off  from  the  ileum  from  twelve  to 
thirty-six  inches  above  the  ileo-csecal  valve.  Strangulation 
may  take  place  beneath  an  adherent  appendix,  a  Fallopian 
tube,  a  portion  of  mesentery,  or  the  pedicle  of  an  ovarian 
tumor,  or  it  may  take  place  in  an  omental  or  a  mesenteric 
aperture.  Strangulation  by  bands  or  apertures  usually  in- 
volves the  ileum,  and  sometimes  the  colon.  This  form  of 
obstruction  is  identical  with  hernia  excepting  in  the  absence 
of  an  external  protrusion. 

2.  Volvulus,  or  twisting  of  the  bowel.  The  twist  may  be 
about  the  mesenteric  axis  or  on  the  axis  of  the  bowel  itself, 
or  two  intestinal  coils  may  be  twisted  together.  Volvulus  is 
commonest  in  the  sigmoid  flexure. 

3.  Intussusception  is  the  invagination  of  a  portion  of  bowel- 
wall  into  the  lumen  of  an  adjacent  part.  One-third  of  all 
cases  of  obstruction  are  due  to  this  cause  (Treves).  There 
are  four  varieties :  the  ileo-ccBcal,  in  which  the  ileum  and  the 
ileo-caecal  valve  pass  into  the  caecum  and  colon ;  the  colic^ 
in  which  the  large  intestine  is  prolapsed  into  itself;  the  ileal, 
in  which  the  small  intestine  alone  is  involved  ;  and  the  ileo- 
colic, in  which  the  ileum  prolapses  through  the  ileo-caecal 
valve.  The  first  variety  is  the  commonest.  Intussusception 
is  due  to  active  peristalsis. 

4.  Stricture  of  the  intestine,  which  stricture  may  be  either 
cicatricial  or  cancerous. 

5.  Obstruction  by  Tumors  of  the  Bowel  and  by  Foreign 
Bodies. — Tumors  may  be  innocent  or  malignant.  Foreign 
bodies  include  certain  substances  that  have  been  swallowed, 
gall-stones,  and  enteroliths,  or  intestinal  calculi.  Foreign 
bodies  are  apt  to  lodge  in  the  lower  portion  of  the  ileum  or 


DISEASES  AND   IXJURIES    Of   THE   ABDOMEX.       615 

in  the  caecum,  and  they  may  cause  ulceration  at  the  seat 
of  lodgement.  If  a  gall-stone  is  sufficiently  large  to  cause 
obstruction,  it  cannot  have  passed  the  duct,  but  must  have 
ulcerated  into  the  bowel  from  the  gall-bladder  (Treves). 

6.  Obstruction  by  tumors^  etc,  outside  the  bozvel,  among  the 
causes  of  which  are  retroflexion  or  retroversion  of  the  womb, 
especially  in  pregnancy,  cysts  or  tumors  of  the  kidneys, 
ovaries,  uterus,  etc.,  and  enlarged  spleen.  Obstruction  from 
any  of  the  above  causes  takes  place  in  the  rectum  or  the 
sigmoid  flexure. 

7.  Obstruction  from  fecal  acciimulatio)i  is  due  to  paresis 
or  paralysis  of  the  bowel  and  the  diminution  or  abolition  of 
peristalsis.  Paresis  or  paralysis  arises  in  the  colon.  Treves 
mentions  among  the  rare  forms  of  obstruction  kinking  of 
the  bowel,  adhesions  matting  the  bowels  together  or  com- 
pressing the  gut,  and  shrinking  of  the  mesentery. 

Symptoms  of  Acute  Obstruction. — Severe  colic  comes 
on  suddenly,  the  pain  varying  in  intensity,  but  at  no  time 
entirely  ceasing ;  there  is  constipation  which  soon  becomes 
absolute,  not  even  wind  being  passed ;  vomiting  is  early — 
first  of  the  contents  of  the  stomach,  next  of  bilious  matter, 
and  finally  of  feces  (stercoraceousj ;  the  abdomen  becomes 
distended  and  tender ;  some  fever  may  be  found  at  the  start, 
but  collapse  soon  arises  ;  the  temperature  is  subnormal ;  the 
face  is  Hippocratic ;  the  pulse  is  rapid  and  feeble ;  and  the 
amount  of  urine  passed  is  veiy  small.  In  obstruction  of  the 
upper  third  of  the  ileum  true  fecal  vomiting  cannot  occur. 
The  tongue  is  dry,  the  mind  is  clear,  and  muscular  cramp 
may  occur.  Intestinal  peristalsis  above  the  obstruction  may 
be  detected  throucrh  the  abdominal  wall.  If  obstruction  is 
high  up  in  the  small  intestine,  tympanites  does  not  occur. 

Symptoms  of  Chronic  Obstruction. — At  intervals  there 
arise  attacks  of  pain  which  become  gradually  more  frequent 
and  severe  ^nd  are  linked  with  vomiting  and  constipation, 


6l6  A   MANUAL    OF  SURGEKY. 

the  vomiting  not  being  stercoraceous  and  the  constipation 
not  being  absolute.  Between  the  painful  seizures  the  patient 
complains  of  constipation  alternating  with  fluid  diarrhoea, 
distention  of  the  belly,  some  abdominal  uneasiness,  anorexia, 
and  dyspepsia.  The  attacks  recur  with  increasing  frequency 
and  severity,  and  acute  obstruction  may  arise  or  the  patient 
may  be  worn  out  by  pain,  vomiting,  and  want  of  food. 

Diagnosis. —  T/ie  determination  of  the   seat  of  lesion  re- 
quires rectal  examination.     An  intussusception  may  some- 
times be  felt.    Vaginal  examination  may  be  demanded.    Pain 
is  apt  to  arise  at  the  seat  of  obstruction  or  to  radiate  from 
there.     Palpation  may  detect  a  tumor.     Rectal  insufflation 
of  hydrogen   may  locate  the  obstruction  by  causing  great 
distention  below  it.     Entire  suppression  of  urine,  early  vomit- 
ing which  is  not  truly  stercoraceous,  absence  of  abdominal 
distention,  and  rapid  collapse,  mean  obstruction  in  the  duo- 
denum or  in  the  jejunum.     Early  vomiting,  which  is  often 
stercoraceous  in  a  rapidly  progressive  case  with  great  dis- 
tention  of  the  umbilical   region,  means  obstruction  of  the 
ileum   or  the    csecum    (Pepper).     Distention   of  the    entire 
abdomen    and    of  the    flanks,  linked   with    tenesmus,   with 
less   intensity  of  symptoms,  less   rapidity  of  progress,   and 
less  diminution  of  urine  than  in  the  above-cited  forms,  means 
obstruction  low  down  in  the  colon  or  in  the  rectum  (Pepper). 
A  test  for  obstruction  in  the  adult  large  intestine  is  an  injec- 
tion by  a  fountain  syringe  :  if  six  quarts  can  be  introduced, 
there  is  no  obstruction  in  the  large  intestine  ;  if  less  than  four 
quarts  can  be  introduced,  there  is  probably  obstruction  in 
the  large  intestine.     The  passage  of  a  sound  in  the  rectum 
is  generally  useless  and  is  often  unsafe. 

The  determination  of  the  causative  condition  is  always  diffi- 
cult and  is  often  impossible.  Intussusception  is  the  common 
cause  in  children.  A  tumor  can  usually  be  felt  in  the  right 
iliac   fossa,  tenesmus  exists,  and  bloody  mucus  is  passed. 


DISEASES  AND  INJURIES   OE   THE  ABDOMEN.       617 

The  abdomen  is  rarely  distended  or  tender.  Vomiting 
occurs,  but  it  is  seldom  stercoraceous.  The  prolapse  may 
be  detected  by  a  finger  in  the  rectum.  In  obstruction  from 
bands,  internal  hernia,  etc.  there  is  a  record  of  peritonitis, 
of  a  traumatism,  of  a  violent  effort,  or  of  pelvic  pain.  The 
attack  is  sudden  in  onset,  is  fierce  in  character,  and  is 
usually  excited  by  violent  exercise  or  the  taking  of  food. 
Vomiting  is  early  and  intractable,  and  it  soon  becomes 
stercoraceous ;  pain  is  violent ;  tympanites  and  abdominal 
tenderness  appear  after  the  attack  has  lasted  for  some  little 
time ;  obstruction  is  complete,  no  wind  even  being  passed ; 
collapse  soon  appears ;  no  tumor  can  be  detected,  and  rectal 
exammation  is  negative.  Volvulus,  which  is  usually  located 
in  the  sigmoid  flexure,  is  preceded  by  constipation.  The 
symptoms  come  on  with  explosive  suddenness,  and  rapidly 
attain  great  severity.  Constipation  is  absolute ;  vomiting  is 
late  and  is  rarely  stercoraceous ;  no  tumor  can  be  detected ; 
rectal  examination  is  negative ;  abdominal  distention  and 
tenderness  are  early  and  pronounced ;  collapse  is  not  so 
rapid  or  so  grave  as  in  the  previously-considered  forms. 
Obstruction  by  a  foreign  body  may  sometimes  be  inferred 
by  the  history  of  some  such  body  having  been  swallowed. 
The  obstructing  body  can  occasionally  be  felt  during  palpa- 
tion. Abdominal  distress  may  exist  for  days  or  weeks  before 
obstruction  occurs.  Vomiting  is  late  and  is  rarely  severe, 
but  pain,  tenderness,  and  distention  are  marked.  In  obstruc- 
tion from  gall-stones  there  will  be  a  record  of  one  or  more 
attacks  of  hepatic  colic.  Pain  is  early  and  acute,  and  vomit- 
ing is  invariable  and  usually  becomes  stercoraceous.  In 
obstruction  from  fecal  accurnulation  chronic  obstruction 
evolves  into  acute  obstruction,  pain  and  vomiting  are  late 
or  even  absent,  and  the  mass  of  feces  can  often  be  felt  by 
rectal  examination  or  by  abdominal  palpation.  In  some  cases 
the  fluid  elements  of  the  feces  pass,  but  the  solid  elements 


6l8  A    MANUAL    OF  SURGERY. 

agglutinate  on  the  walls  of  the  bowel  (the  diarrhoea  of  consti- 
pation). Obstruction  from  strictures  or  from  pressure  comes 
on  acutely  after  a  prolonged  period  of  disturbance,  during 
which  period  occurred  attack  after  attack  of  temporary 
obstruction,  complete  or  partial.  A  history  of  blood  or  pus 
in  the  stools  would  indicate  tumor  of  the  bowel ;  a  history 
of  blood  or  pus  having  been  absent  would  indicate  pressure 
from  without  (Pepper).  In  functional  obstruction  there  is  no 
local  pain,  no  tenderness,  no  tumor,  no  tendency  to  collapse, 
but  simply  distention  and  absolute  constipation,  and  pos- 
sibly non-fecal  vomiting  occurring  in  a  neurotic  or  hysterical 
subject.  A  phantom  tumor  due  to  a  local  distention  of  the 
intestine  from  limited  muscular  spasm  disappears  under 
ether. 

Separation  of  Intestinal  Obstruction  from  Other  Diseases. — 
Always  examine  for  a  strangulated  hernia  at  every  hernial 
outlet.  If  obstruction  is  complicated  with  an  irreducible 
hernia  above  the  seat  of  lesion,  the  hernia  will  always  enlarge 
and  become  tender  because  of  accumulation  of  feces  (Pepper). 
Functional  obstruction  may  attend  peritonitis  or  may  fol- 
low the  reduction  of  a  hernia.  Appendicitis  with  peritonitis 
may  cause  symptoms  similar  to  those  of  obstruction,  but 
there  is  fever,  a  history  of  trouble  in  the  right  iliac  fossa, 
and  the  vomiting  is  not  stercoraceous.  Pepper  says  that 
acute  hemorrhagic  pancreatitis  produces  symptoms  so  nearly 
identical  with  those  of  intestinal  obstruction  that  a  diagnosis 
cannot  be  made.  Poisoning  by  arsenic  or  by  corrosive  sub- 
limate should  not  be  confounded  with  intestinal  obstruction. 

Prog-nosis. — Without  surgical  interference  most  cases  of 
acute  intestinal  obstruction  die  within  ten  days,  usually 
within  seven  days.  Death  may  be  due  to  shock,  to  ex- 
haustion, to  perforation,  to  peritonitis,  or  to  obstruction  of 
respiration  and  circulation  by  tympanites.  Recovery  occa- 
sionally happens  by  the  formation  of  a  fistula  externally  or 


DISEASES  AND   INJURIES   OF   THE  ABDOMEN      619 

into  another  portion  of  the  bowel.  In  acute  obstruction  from 
foreign  bodies  the  obstructing  body  occasionally  passes. 
Volvulus  and  strangulation  by  bands  are  almost  invariably 
fatal  unless  an  operation  is  performed.  In  intussusception 
recovery  occasionally  follows  the  sloughing  away  of  the  pro- 
lapsed gut,  but  stricture  almost  inevitably  follows  this  rare 
event.  Functional  obstruction  gives  a  good  prognosis.  The 
prognosis  of  chronic  obstruction  depends  upon  the  causa- 
tive lesion,  and  is  not  nearly  so  grave  as  is  that  of  acute 
obstruction. 

Treatment. — In  acute  obstruction  it  is  usually  customary 
to  empty  the  stomach  by  lavage  and  to  evacuate  the  rectum 
by  means  of  copious  injections  given  while  the  patient  is  in 
the  knee-chest  position.  Hutchinson's  method  of  taxis  and 
massage  is  uncertain,  and  is  more  liable  to  inflict  harm  than 
to  confer  benefit.  Some  surgeons  apply  constant  compres- 
sion to  the  abdomen  by  means  of  straps  of  adhesive  plaster. 
Puncture  of  the  intestine  with  an  aseptic  hypodermatic  needle 
introduced  obliquely  will  relieve  gaseous  distention.  The 
passage  of  a  small  tube  from  the  anus  to  the  sigmoid  flexure 
will  empty  the  colon  of  gas  if  no  obstruction  intervene.  In 
intussusception,  give  no  food  by  the  stomach,  give  opium  and 
belladonna  to  stop  peristalsis,  and  distend  the  bowel  below 
the  obstruction  with  hydrogen  gas.  Wash  out  the  rectum 
with  copius  injections,  give  an  anaesthetic,  and  insufflate  the 
gas.  If  this  fails,  and  the  condition  of  the  patient  is  good, 
perform  laparotomy.  In  obstruction  from  fecal  impaction, 
use  large  rectal  injections  and  give  small  repeated  doses  oC 
salines  or  a  mixture  of  castor  oil  and  oil  of  turpentine. 
If  there  are  signs  of  inflammation,  do  not  give  cathartics, 
even  in  small  doses,  but  give  opium  and  belladonna  to  arrest 
vomiting  and  to  relax  spasm.  Impactions  in  the  rectum  can 
be  spooned  away.  In  acute  intestinal  obstruction,  if  the 
symptoms  grov\^  worse,  do  not  wait,  but  open  the  abdomen 


620  A   MANUAL    OF  SURGERY. 

before  collapse  comes  on  and  find  the  cause  of  the  obstruc- 
tion. If  it  is  a  gall-stone  or  enterolith,  try  to  crush  it  without 
opening  the  intestine  ;  if  this  fails,  push  it  up  a  little  distance, 
incise  the  bowel,  remove  the  stone,  and  close  the  incision 
with  Lembert  sutures.  If  there  be  fecal  obstruction,  break 
up  the  masses  by  pressure  and  push  the  fecal  plug  down.  If 
there  be  intussusception,  reduce  the  prolapse  and  shorten 
the  mesentery,  but  if  reduction  is  impossible  perform  an 
anastomosis,  or  a  resection  and  enterorrhaphy,  or  make  an 
artificial  anus.  In  volvulus  untwist  and  shorten  the  mesen- 
tery, but  if  this  is  impossible  treat  as  an  irreducible  invagi- 
nation. In  obstruction  from  adhesions,  try  to  separate  them 
and  straighten  out  the  bowel,  stitching  healthy  peritoneum 
over  each  raw  spot  to  prevent  recurrence.  Anastomosis 
may  be  necessary.  In  flexion,  separate  the  intestine,  remove 
the  flexion  by  a  V-shaped  incision,  and  suture  the  wound 
in  the  bowel  (Senn).  In  chronic  obstruction  it  is  often 
advisable  to  perform  an  exploratory  laparotomy  and  deter- 
mine by  the  condition  what  is  to  be  done.  Some  tumors 
external  to  the  bowel  are  removed.  Growths  in  the  bowel- 
wall  may  be  removed  by  resection  of  the  involved  portion 
of  intestine.  Anastomosis  may  be  performed,  or  an  artificial 
anus  may  be  necessary. 

Appendicitis. — Appendicitis,  which  is  an  inflammation 
of  the  vermiform  appendix  of  the  caecum,  is  almost  in- 
variably the  primary  lesion  of  all  of  those  various  con- 
ditions known  as  typhlitis,  perityphlitis,  paratyphlitis,  etc. — 
terms  which  no  longer  imply  pathological  entities,  and 
are  in  most  instances  well  relegated  to  obscurity.  The 
appendix  is  a  diverticulum  (musculo-membranous  in  struc- 
ture) which  comes  from  the  posterior  and  internal  part  of 
the  head  of  the  colon,  and  which  has  no  physiological 
function  (in  herbivora  and  rodents  it  is  a  functionally  active 
organ).     The  structure  of  the  appendix  is  identical  with  the 


DISEASES  AND   INJURIES   OF  THE  ABDOMEN.      62 1 

structure  of  the  colon.  The  appendix  averages  about  four 
and  a  half  inches  in  length,  and  its  diameter  is,  as  a  rule, 
about  equal  to  that  of  a  No.  9  English  bougie ;  its  canal  is 
narrow  and  is  partly  closed  by  the  valve  of  Gerlach  (Tala- 
mon),  '  The  appendix  enters  the  caecum  at  its  posterior  in- 
ternal part,  which  part  is  usually  the  seat  of  the  most  intense 
pain  in  inflammation ;  it  is  known  as  "  McBurney's  point," 
and  corresponds  to  a  point  on  the  surface  two  inches  from 
the  spine,  on  a  line  drawn  from  the  umbilicus  to  the  anterior 
superior  iliac  spine.  The  free  part  of  the  appendix  in  one- 
third  of  all  persons  is  in  relation  with  the  posterior  surface 
of  the  caecum ;  in  almost  one-third  of  all  persons  it  is  fixed 
in  the  iliac  fossa,  so  that  if  perforation  occurs  the  contents 
will  be  voided  in  the  retroperitoneal  tissue  (iliac  abscess). 
In  some  cases  it  is  external  to  the  caecum ;  in  some  it  passes 
downward,  and  in  some  inward.  In  about  two-thirds  of  all 
cases  the  appendix  is  completely  covered  with  peritoneum ; 
in  one-third  of  all  cases  it  is  in  contact,  in  some  part  of  its 
length,  with  cellular  tissue  (Talamon). 

Etiology  and  Patliology. — Appendicitis  is  very  rare  in  in- 
fants, but  is  common  at  any  period  beyond  childhood.  Non- 
traumatic catarrhal  or  ulcerative  inflammation  may  arise,  prob- 
ably from  the  action  of  the  bacterium  coli  commune  of 
Escherich.  When  non-traumatic  inflammation  occurs,  swell- 
ing of  the  mucous  membranes  occludes  the  opening  into  the 
colon,  and  the  lumen  of  the  appendix  increases  and  fills 
up  with  a  thick  or  muco-purulent  fluid.  Ulcers  sometimes 
form,  which  may  only  involve  the  mucous  membrane,  may 
pass  deeply  into  the  coats,  or  may  even  perforate.  A  com- 
mon cause  of  appendicitis  is  the  presence  of  scybala,  which  are 
little  masses  of  hardened  feces  that  are  at  first  moist  and  soft, 
but  soon  become  dry  and  hard.  They  are  usually  formed  in 
the  caecum,  and  not  in  the  appendix.  This  fact  is  proved 
by  their  outline  rarely  being  that  of  the  appendix  (Talamon). 


622  A   MANUAL    OF  SURGERY. 

These  scybala  are  formed  by  small  portions  of  feces  lodging 
in    depressions    found    between    the    longitudinal    muscular 
fibres  of  the  colon,  taking  the    shape  of  the    depressions, 
and  being  forced  out  by  peristalsis.     Talamon  states  that  a 
concretion  may  form  in  a  very  large  appendix.     When  a 
concretion  enters  the  appendix  and  becomes  impacted,  the 
appendix  strives  to  expel   it  by  muscular  contraction,  and 
violent  symptoms  are  produced  (appendicular  colic).     For- 
eign bodies,  such  as  pins,  fish-bones,  and  grape-seeds,  may 
enter  the  appendix,  but  they  do  so  far  less  often  than  is  gen- 
erally supposed,  most  alleged  grape-seeds  from  the  appendix 
being  only  fecal  concretions.     Appendicitis  due  to  a  foreign 
body,  such  as  a  grape-seed  or  a  pin,  is  known  as  traumatic ; 
appendicitis  due  to  a  concretion  is  known  as  stercoral.     A 
foreign  body  may  produce  instant  perforation  at  the  site  of 
the    body.     If  impaction    of  a  foreign  body  or  concretion 
occurs,  the  orifice  of  the  appendix  is  closed,  the  circulation 
is  soon  cut  off,  the  secretions  are  retained,  the  coats  become 
congested,  the  diverticulum  enlarges  enormously,  microbes 
multiply  with  great  rapidity,  and  the  wall  of  the  congested 
appendix  inflames  and   ulcerates    and  is  finally  perforated. 
Some  hold  that  catarrhal  appendicitis  can  result  from  exten- 
sion of  a  catarrh  of  the  colon  and  can  arise  from  external 
traumatism!.     If  before  a  perforation  the  appendix  adheres 
to  the  cellular  tissue  behind  the  caecum,  cellulitis  or  abscess 
without  peritonitis  may  result.     When  appendicitis  goes  on 
to  perforation,  there  is  almost  always  some  peritonitis ;  but 
if  the  steps  to  perforation  are  gradual,  the  peritonitis  may 
be  local,  and  will  sometimes  by  effusion  of  lymph  make  a 
barrier   between    the    appendix    and    the    peritoneal    cavity 
before  perforation    occurs.     When    perforation  takes   place 
at  all  suddenly,  septic  peritonitis  is  inevitable.     Peritonitis 
can  arise  without  perforation  by  contiguity  of  structure  or 
by  migration  of  the  bacterium  coli  commune  through  the 


DISEASES  AND   INJURIES   OF   THE  ABDOMEN.       623 

congested  walls  of  an  obstructed  appendix.  In  some  cases 
perforation  takes  place  into  the  peritoneal  cavity,  but  pus  is 
circumscribed  by  matting  together  of  the  intestines  with 
plastic  exudate.  The  appendix  may  become  gangrenous 
very  rapidly  or  after  some  time.  In  some  cases,  if  the  per- 
foration is  very  small  and  the  appendix  is  swathed  in  lymph, 
or  if  perforation  does  not  occur,  the  inflammation  may  sub- 
side. Perforation  rarely  occurs  from  liquid  pressure  or  from 
the  pressure  of  concretion;  it  is  generally  due  to  ulceration 
or  to  the  action  of  micro-organisms.  Appendicitis  which 
subsides  may  at  any  time  recur,  and  the  life  of  the  patient 
is  under  constant  menace.  An  enormous  number  of  people 
have  had  appendicitis.  Toft  recorded  five  hundred  autopsies, 
and  in  thirty-six  per  cent,  of  them  there  were  positive  signs 
of  past  attacks.  The  disease  is  often  unsuspected  in  life. 
These  facts  prove  that  the  disease  may  subside  without  the 
aid  of  surgery. 

Forms  of  Appendicitis. — Simple  parietal  or  catarrhal  ap- 
pendicitis is  not  limited  to  the  mucous  membrane ;  hence 
the  term  catarrhal  is  not  strictly  correct.  Forty-eight  hours 
after  the  mucous  coat  begins  to  inflame,  the  peritoneal  coat 
will  be  involved.  In  simple  appendicitis  the  diverticulum 
enlarges,  fills  up  with  mucus,  and  its  coats  become  infiltrated 
With  inflammatory  exudate.  This  inflammation  may  undergo 
resolution  or  suppuration,  or  may  become  chronic.  In  a 
catarrhal  inflammation  secondary  to  catarrh  of  the  colon 
the  case  may  be  chronic  from  its  origin.  If  inflammation 
obliterates  the  lumen  of  the  appendix,  the  condition  is  de- 
nominated obiiteraiive  appendicitis  (Senn).  In  appendicitis 
from  a  concretion  the  attack  may  subside,  the  fluid  elements 
may  be  absorbed  or  flow  back  into  the  bowel,  and  resolution 
of  the  exudate  may  take  place,  but  if  the  concretion  remains 
in  the  appendix  recurrence  is  probable.  Recurrent  ap- 
pendicitis m^y  be  due  to  inordinate  size  of  the  mouth  of 


624  ^    MANUAL    OF  SURGERY. 

the  appendix,  making  of  this  diverticulum  a  drag-net  for 
foreign  bodies.  Suppurative  appoidicitis  is  due  to  puru- 
lent infiltration  of  the  walls.  Pus  in  the  lumen  is  not 
purulent  appendicitis.  Gangrenous  appeneiicitis  is  a  moist 
or  septic  gangrene,  due  to  interference  with  the  circulation 
by  an  impaction  near  the  base  and  to  tissue-destruction  by 
the  action  of  micro-organisms.  Perforations  occur,  and  they 
are  often  multiple. 

Symptovis. — The  disease  is  often  ushered  in  by  appen- 
dicular colic,  which  is  apt  to  arise  after  partaking  of  an  in- 
digestible meal  or  after  indulging  in  violent  exertion.  Pain 
of  a  colicky  nature  begins  in  the  right  iliac  fossa  and  radiates 
to  the  umbilicus ;  tenderness  does  not  at  first  exist  in  the 
fossa.  Nausea  and  vomiting  occur  ;  constipation  is  usual,  but 
it  may  alternate  with  diarrhoea.  This  condition  may  pass 
away  or  may  go  on  to  inflammation.  Appendicitis  may  follow 
colic  or  may  appear  without  a  preceding  colic,  and  it  is  mani- 
fested by  violent  abdominal  pain  which  is  aggravated  by  move- 
ment, by  pressure,  and  by  breathing.  This  pain  is  usually 
intense  in  the  right  iliac  fossa,  but  radiates  to  the  umbilicus 
or  even  over  the  entire  abdomen.  The  patient  lies  upon  the 
right  side  and  draws  up  the  right  leg.  The  abdomen  is  dis- 
tended and  rigid.  Tenderness  exists  in  the  right  iliac  fossa, 
and  the  point  of  greatest  tenderness,  which  is  known  as 
"  McBurney's  point,"  is  apt  to  be  about  two  inches  from  the 
anterior  superior  spine,  on  a  line  drawn  from  the  spine  to  the 
umbilicus.  Irregular  fever  arises.  The  pulse  becomes  fre- 
quent and  hard.  The  respiration  is  shallow  and  thoracic. 
Occasionally  a  chill  occurs.  Vomiting  is  common.  Great 
thirst,  anorexia,  and  obstinate  constipation  exist.  Hiccough 
is  not  unusual.  The  urine  is  scanty  and  high  colored.  The 
face  is  anxious  and  expressive  of  pain.  If  the  inflammation 
continues,  in  from  one  to  two  days  a  swelling  may  often  be 
detected  in  the  right  iliac  fossa.    This  swelling  may  be  small 


DISEASES  AND   INJURIES   OF   THE  ABDOMEN.      62$ 

or  large,  distinct  or  obscure  ;  it  may  be  detected  by  palpation 
of  the  abdomen  alone  or  by  palpation  with  a  finger  in  the 
rectum.  If  the  tenderness  is  great  and  the  abdomen  tense, 
ether  may  be  required  to  determine  the  nature  and  extent 
of  th6  swelling.  In  perforative  appendicitis  an  initial  chill 
may  occur,  and  the  pain  is  very  violent;  there  are  fever, 
coated  tongue,  vomiting,  excessive  tenderness,  and  frequent 
pulse.  Tympanites  is  the  rule,  but  the  belly  may  be  flat, 
and  collapse  rapidly  arises.  If  abscess  forms,  there  may 
be  cedema  of  the  skin  or  e\^en  fluctuation.  In  sudden 
perforation  there  is  collapse  and,  if  reaction  occurs,  septic 
peritonitis.  In  gangrenous  appendicitis  there  are  sepsis 
and  collapse.  It  is  often  impossible  to  distinguish  the 
form  of  an  appendicitis,  but  remember  that  sudden  pain 
and  local  tenderness  in  the  iliac  fossa,  with  fever,  mean  ap- 
pendicitis, whether  a  swelling   is  found  or  not. 

In  a  mild  case  resolution  occurs,  pain  diminishes,  the  bowels 
move,  fever  disappears,  and  in  a  week  or  so  the  patient  feels 
all  right.  In  more  severe  cases  local  peritonitis  arises,  or 
suppuration  occurs  with  irregular  fever,  or  perforation  takes 
place,  or  the  appendix  becomes  gangrenous.  Pus  may  be 
evacuated  into  the  bowel,  into  a  cavity  formed  by  lymph 
(appendicular  abscess),  into  the  cellular  tissue  back  of  the 
colon,  or  into  the  peritoneal  cavity.  Evacuation  of  pus  into 
the  peritoneal  cavity  causes  collapse  and  septic  peritonitis. 
Catarrhal  appendicitis  is  apt  to  be  mild,  but  not  of  necessity, 
as  it  may  cause  the  gravest  symptoms.  The  pains  of  colic 
are  due  to  appendicinal  contractions  attempting  to  force  out 
a  foreign  body  or  imprisoned  mucus.  The  pains  of  begin- 
ning perforation  are  localized,  intense,  and  accompanied  by 
the  tenderness  of  a  local  peritonitis. 

Trcatiiicnt. — In  appendicular  colic  a  saline  is  to  be  given, 
followed,  after  a  movement  occurs,  by  opium.  If  tenderness 
exists,    do    ffot   give    a   purgative,  because    in    appendicitis 

40 


626  A   MANUAL    OF  SURGERY. 

violent  peristalsis  may  produce  perforation.  The  old  theory 
of  fecal  impaction  in  the  head  of  the  colon  has  been  ex- 
ploded by  Weir,  Bull,  Dever,  Keen,  and  others,  who  have 
never  seen  it.  In  an  appendicitis  even  with  slight  symptoms 
many  surgeons  maintain  that  an  operation  should  be  per- 
formed, because  slight  symptoms  are  no  sign  that  even  in  an 
hour  or  two  gangrene  or  perforation  will  not  occur.  Early 
operation  is  comparatively  safe ;  operation  after  perforation, 
gangrene,  or  septic  peritonitis  arises  must  be  done,  but  it  is 
usually  futile.  Other  surgeons,  in  a  first  attack,  if  the  symp- 
toms are  mild,  wait  and  temporize,  apply  a  hot-water  bag 
over  the  right  iliac  fossa  to  favor  plastic  exudation,  and  give 
opium  in  full  doses.  Some  open  the  case  with  salines,  apply 
an  ice-bag  over  McBurney's  point,  and  after  a  free  movement 
of  the  bowels  give  opium  and  keep  the  patient  on  liquid 
diet.  If  the  symptoms  become  worse,  they  recommend 
operation.  In  recurrent  appendicitis,  after  the  attack  passes 
away,  operate.  In  any  severe  case,  in  a  case  with  distinct 
swelling,  and  in  any  case  where  suppuration,  gangrene,  or 
perforation  are  thought  to  have  occurred  or  to  be  liable 
to  occur,  operate  at  once.     (See  Operation  for  Appendicitis}^ 

Peritonitis. — In  rare  instances  peritonitis  is  said  to  be 
primary,  following  a  cold  ;   but  most  surgeons  doubt  this. 

Plastic  peritonitis  is  due  to  an  aseptic  cause  (traumatism 
or  chemical  irritation);  it  remains  limited,  and  is  really  a 
process  of  repair  rather  than  of  inflammation.  The  symp- 
toms of  plastic  peritonitis  are  local  pain,  tenderness,  and 
rigidity.  Fever  exists,  due  to  the  absorption  of  fibrin-ferment 
and  the  products  of  tissue-change ;  adhesions  form,  which 
may  be  either  temporary  or  permanent.  Recovery  is  the 
rule.  The  treatment  comprises  saline  purgatives  followed 
by  rest,  opiates,  a  liquid  diet,  and  local*  heat  (hot-water  bag 
or  fomentations). 

Septic  peritonitis  is  apt  to  destroy  life  even  before  the 


DISEASES  AND   INJURIES   OF   THE   ABDOMEN.       627 

peritoneum  presents  any  marked  change.  Death  ensues 
from  the  absorption  of  toxic  alkaloids.  Septic  peritonitis 
may  arise  during  puerperality,  through  lymphatic  infection ; 
it  may  be  due  to  infection  from  without  by  an  operation  or 
an  accident,  to  perforation  of  an  ulcer,  to  gangrene  of  a 
portion  of  the  intestine,  to  rupture  of  an  abscess  into  the 
peritoneal  cavity,  or  to  migration  of  micro-organisms  through 
a  damaged  wall  of  the  bowel.  It  is  made  manifest  by  a 
chill,  a  shock,  or  rapid  collapse,  very  rapid  pulse,  tempera- 
ture which  is  apt  to  be  subnormal  or  to  soon  become  so, 
dry  tongue,  delirium,  persistent  vomiting,  and  often,  but  not 
invariably,  distention.  In  puerperal  peritonitis  or  septic 
peritonitis  from  operation  there  is  often  no  pain ;  in  perfora- 
tive peritonitis  there  is  acute  pain.  Patients  usually  die 
within  five  or  six  days.  Treatment  is  rarely  successful.  The 
abdomen  is  opened,  flushed  out,  and  drained,  and  any  per- 
foration is  closed.  Stimulants  are  strongly  pushed.  The 
patient  is  fed  upon  liquids  (koumiss  especially). 

In  fibrino -plastic  peritonitis  the  septic  organisms  are 
fewer  or  less  virulent,  the  products  of  gerni-action  are  lim- 
ited and  surrounded  by  adhesions,  and  circumscribed  sup- 
purative peritonitis  is  apt  to  arise. 

Suppurative  peritonitis  differs  clinically  from  septic  peri- 
tonitis in  the  fact  that  it  is  more  apt  to  be  circumscribed 
and  less  apt  to  be  fatal.  The  causes  of  both  are  identical. 
In  septic  peritonitis  death  occurs  from  absorption  of  pto- 
maines before  obvious  pathological  changes  occur  in  the 
peritoneum ;  in  suppurative  peritonitis  the  microbes  are 
fewer,  are  less  virulent,  or  vital  resistance  is  more  decided, 
and  suppuration  follows  marked  changes  in  the  peritoneum. 
In  suppurative  appendicitis  the  pyogenic  bacteria  are  always 
present,  and  there  exists  in  the  peritoneum  a  wound  or 
damaged  area  to  constitute  a  point  of  least  resistance. 

Symptoms. — Chilliness  or  a  rigor  is  common,  followed  by 


628  A   MANUAL    OF  SURGERY. 

fever,  the  temperature  rising  to  102°  or  104°  ;  pain  is  intense, 
and  is  accentuated  by  motion  and  pressure ;  the  attitude  of 
the  patient  is  assumed  to  reHeve  pain  (he  lies  upon  his  back, 
with  the  shoulders  raised  and  the  thighs  drawn  up) ;  there 
are  vomiting,  obstinate  constipation,  and  distention  and 
rigidity  of  the  abdominal  walls.  The  constipation  may  be 
due  either  to  tympanitic  distention  or  to  the  shock  of  a 
perforation  inhibiting  intestinal  peristalsis.  In  perforation 
gas  often  passes  into  the  peritoneal  cavity  and  obscures  the 
liver-dulness ;  in  tympanites  without  perforation  the  liver  is 
pushed  up  and  its  dulness  remains,  but  on  a  higher  level. 
Pus  unconfined  by  adhesions  will  gravitate  to  the  most 
dependent  part  of  the  peritoneal  cavity.  Circumscribed  sup- 
purative peritonitis  presents  the  signs  of  a  deep  abscess. 
In  some  cases  of  suppurative  peritonitis  there  is  no  tym- 
panitic distention  or  rigidity;  in  some  cases  there  is  no 
fever,  and  a  subnormal  temperature  may  even  exist.  The 
high-tension  pulse  of  peritonitis  is  due  to  the  tympanitic  dis- 
tention emptying  the  bowel-walls  of  blood,  and  thus  increas- 
ing the  amount  of  fluid  in  the  other  vessels  of  the  body. 

Treatment. — In  the  beginning  of  ordinary  peritonitis  with- 
out perforation,  give  a  saline  cathartic,  which  will  empty  the 
peritoneal  cavity  of  fluid,  will  favor  the  elimination  of  mi- 
crobes, and  will  combat  inflammation.  The  old-time  remedy 
was  opium,  but  Tait  proved  its  inefficiency,  and  showed  that 
it  masked  the  symptoms  and  often  created  a  false  sense  of 
security  in  the  very  midst  of  imminent  dangers.  The  usual 
method  of  administering  salines  is  to  give  5J  of  Rochelle  salt 
and  3j  of  Epsom  salt  every  hour  until  a  free  movement 
occurs.  This  treatment  will  often  cut  short  a  beginning 
peritonitis.  Give  an  enema  of  turpentine  at  the  same  time 
as  the  saline.  After  the  bowels  move,  give  opium  for  pain. 
If  this  treatment  fails,  open  the  belly,  explore  for  the  causa- 
tive  condition,  remedy  it,  flush,  and   drain.     In  perforative 


DISEASES  AXD   IXJURIES   OF  THE  ABDOMEN.      629 

peritonitis  do  not  give  cathartics :  they  will  only  increase  the 
extravasation  and  prevent  its  limitation  by  lymph.  In  per- 
forative peritonitis  perform  a  laparotomy,  suture  the  perfora- 
tion, flush  out  the  belly,  and  drain.  A  circumscribed  abscess 
is  to  be  opened  and  the  primary  lesion  sought  for  and,  if  found, 
removed.  Do  not  tear  up  the  lymph  barriers  in  an  attempt  to 
find  the  primary  lesion  ;  rather  let  it  go  undiscovered.  Pack 
iodoform  gauze  against  the  intestines  to  reinforce  the  barrier 
of  lymph,  and  insert  a  tube.  Every  patient  with  peritonitis 
requires  stimulants  and  frequent  feeding  with  liquid  food. 

Tubercular  peritonitis  is  seen  by  the  surgeon  as  a  primary 
local  tuberculosis,  though  it  occurs  also  as  an  associate  of 
phthisis  and  as  a  part  of  a  general  tuberculosis.  Abdominal 
section  with  drainage  cures  not  a  few  cases. 

Operations  upon  the  Abdomen :  Abdominal  Section 
(Coeiiotomy  ;  Laparotomy). — In  opening  the  abdominal  cav- 
ity for  exploratory  purposes  or  to  gain  access  to  some  area 
of  abdominal  or  pelvic  disease,  the  patient  is  carefully 
prepared  as  for  any  operation.  The  instruments  required 
depend  upon  the  nature  of  the  case.  As  a  rule,  there  are 
required  scalpels,  scissors,  a  dry  dissector,  two  pairs  of  dissect- 
ing-forceps,  haemostatic  forceps,  pedicle-forceps,  Hagedorn 
needles,  a  needle-holder,  drainage-tubes,  gauze  pads,  sponges, 
silk,  catgut,  silkworm  gut,  Pacquelin  cautery,  an  electric  light, 
a  bag,  a  tube,  and  a  solution  for  hypodermoclysis.  Always 
count  the  instruments,  sponges,  and  pads,  and  write  down 
the  number. 

Operation. — In  some  cases  the  patient  is  placed  recumbent, 
in  others  is  put  in  the  position  of  Trendelenburg  (Fig.  145). 
The  patient  is  placed  near  the  right  side  of  the  table,  the 
extremities  and  the  chest  are  covered  with  blankets,  and 
sterilized  sheets  are  placed  well  around  the  field  of  opera- 
tion. The  surgeon  steadies  the  skin  of  the  belly  with  the 
fingers  of  his  left  hand,  and,  holding  the  knife  in  the  right 


630 


A    MANUAL    OF  SURGERY. 


Fig.  146. — The  Trendelenburg  Po 
sition. 


hand,  makes  an  incision  about  two  inches  long.  This  incision 
is  often  made  in  the  middle  line,  but  not  invariably,  and  is 
placed  midway  between  the  pubes  and  umbilicus.  The  first 
cut  goes  to  the  aponeurosis.  Clamp  the  vessels.  Do  not  hunt 
for  the  linea  alba  below  the  umbilicus,  but  go  right  through 
or  between  the  recti  muscles.  Divide  the  transversalis  fascia, 
beneath  which  is  a  little  fat,  and  expose  the  peritoneum. 
The  latter  structure  is  recognized  by  its  glistening  appear- 
ance, by  the  ease  with  which  it 
can  be  pinched  up  between  the 
finger  and  thumb,  and  by  the 
readiness  with  which  its  opposed 
surfaces  can  be  made  to  glide  over 
each  other.  On  identifying  the 
peritoneum,  catch  it  at  each  side 
of  the  incision  with  forceps,  lift  it  up,  nick  it  with  a  knife, 
and  open  it  with  scissors  to  the  length  of  the  external  wound. 
To  prevent  the  stripping  of  the  peritoneum,  a  good  plan  is 
to  anchor  it  to  the  belly-wall  with  a  stitch  on  each  side  of 
the  incision.  Through  the  wound  thus  made  the  abdomen 
and  its  contents  are  explored,  the  trouble  located,  and  de- 
termination made  as  to  whether  or  not  operation  is  advis- 
able, and,  if  it  is  advisable,  what  form  it  shall  take.  It  may 
be  necessary  to  enlarge  the  wound.  This  is  done  by  placing 
the  index  and  middle  fingers  of  the  left  hand  in  the  belly, 
with  their  pulps  against  the  peritoneum,  in  the  line  where 
the  surgeon  will  cut,  to  serve  as  supports  to  the  scissors  and 
as  guards  to  intraperitoneal  structures.  The  scissors  are 
introduced  and  the  wound  is  enlarged  upward  around  the 
umbilicus  if  necessary.  As  soon  as  the  incision  is  complete, 
Treves  pushes  a  large  sponge  into  Douglas's  pouch  and 
leaves  it  there  until  the  operation  is  completed.  Slender 
adhesions  are  broken  off  with  the  finger  or  are  pushed  off 
with  gauze ;  firm  adhesions  are  tied  and  cut. 


DISEASES  AND   INJURIES   OF  THE  ABDOMEN.       63 1 

The  toilet  of  the  peritoneum  is  important  after  the  opera- 
tion is  completed.  Following  a  clean  laparotomy,  when  but 
little  blood  has  flowed  into  the  cavity,  flushing  out  is  not 
required  ;  if  much  blood  has  flowed  or  if  any  septic  matter 
has  passed  into  the  peritoneal  cavity,  after  removing  the 
sponge  from  Douglas's  pouch  flush  out  the  belly  thor- 
oughly with  warm  boiled  water,  and  sponge  out  the  fluid 
which  will  not  run  out  by  gravity.  Flushing  is  continued 
until  the  fluid  runs  clear.  Before  closing  the  wound,  stop 
hemorrhage  and  count  the  instruments  and  sponges.  In 
most  instances  drainage  is  not  needed,  but  it  must  be  used 
in  septic  cases  and  when  hemorrhage  has  been  severe.  The 
best  tube  is  the  glass  drain,  which  is  introduced  at  the  lower 
angle  of  the  wound  and  reaches  the  bottom  of  the  pouch  of 
Douglas.  This  tube  is  repeatedly  emptied  during  the  prog- 
ress of  the  case  by  means  of  a  syringe.  In  closing  the  wound 
some  surgeons  close  the  peritoneum  with  a  continuous  cat- 
gut suture  and  close  the  belly-wall  with  interrupted  sutures 
of  silkworm  gut ;  some  operators  close  with  interrupted 
silkworm-gut  sutures,  including  peritoneum,  muscles,  and 
skin  in  each  stitch.  Dress  with  antiseptic  gauze  and  wood- 
wool, and  apply  a  flannel  binder. 

In.  section  for  appendicitis,  make  a  vertical  incision  two 
inches  in  length  and  two  inches  internal  to  the  anterior  supe- 
rior spine  of  the  ilium.  After  opening  the  peritoneum,  find  the 
appendix  by  the  following  method  :  Follow  the  parietal  peri- 
toneum outward  with  the  finger,  then  backward,  then  inward; 
the  first  obstruction  it  encounters  is  the  colon.  Pass  the  fin- 
ger down  to  the  head  of  the  colon,  find  the  appendix,  usually 
posterior  and  internal,  and  lift  it  into  the  wound.  In  most 
cases  the  neck  of  the  appendix  is  tied  with  strong  silk,  gauze 
is  packed  around  it  to  prevent  septic  matter  entering  the 
abdomen,  the  appendix  is  cut  off,  and  the  stump  is  cauter- 
ized with  pure  carbolic  acid  and  is  inverted  into  the  colon  by 


632  A   MANUAL    OF  SURGERY. 

Lembert  sutures.  If  there  is  no  abscess,  perforation,  or  gan- 
grene, drainage  is  unnecessary ;  otherwise  it  is  necessary. 
Always  irrigate.  In  opening  an  abscess  following  perfora- 
tion, explore  very  carefully  for  the  appendix.  When  it  is 
found,  try  and  lift  it  up ;  if  this  is  feasible,  remove  it.  If 
lifting  it  up  is  liable  to  rupture  the  barrier  of  lymph,  leave 
the  appendix  in  place,  irrigate  gently,  pack  iodoform  gauze 
around  to  sustain  the  barrier,  and  put  a  tube  deep  in  the 
centre.  Partially  suture  the  wound.  Remove  the  gauze  about 
the  fourth  day,  but  leave  the  tube  some  days  longer  (Barton). 
Enterorrhaphy,  or  suture  of  the  intestine,  is  to  be  per- 
formed with  fine  silk,  a  small,  round,  calyx-eyed  needle 
(Fig.  147)  being  employed.  Leinberfs  suture  (Fig.  148,  a) 
is  at  right  angles  to  the  wound.  It  goes  down  to,  but  not 
through,  the  mucous  membrane.  It  is  formed  by 
picking  up  a  fold  of  the  intestine  (one-twelfth  to 
one-eighth  of  an  inch  wide)  one-eighth  of  an  inch 
from  the  edge  on  one  side  of  the  wound,  passing  the 
needle  through,  picking  up  a  fold  on  the  opposite 
side  of  the  wound,  and  passing  the  needle  through. 
Eye^of^^th^  On  tying  the  threads  the  serous  membrane  is 
Calyx  -  eyed  inverted  and  peritoneum  is  brought  into  contact 

Needle, 

with  peritoneum.  Dupuytroi  s  suture  (Fig.  148,  b) 
is  a  continuous  Lembert  suture.  The  Czeriiy-Lembert  siiture 
(Fig.  149)  is  a  suture  passed  through  the  serous  membrane 
on  one  side  of  the  wound  and  brought  out  in  the  wound 
without  perforating  the  mucous  membrane.  It  is  re-entered 
at  a  corresponding  point  of  the  wound-surface  of  the  opposite 
side,  and  emerges  at  a  corresponding  point  of  the  serous 
membrane.  A  Lembert  suture  is  added.  Halstead's  suture 
includes  not  only  the  muscular  coat,  but  also  a  portion  of 
the  tough  submucous  coat.  Gushing  s  right-angled  suture 
(Fig.  148,  c)  is  a  continuous  suture  going  through  the  mus- 
cular coat  and  serving  to  invert  the  serous  layer.    Joberfs 


0 


DISEASES  AND   INJURIES    OF   THE   ABDOMEN.      633 


Fig.  148. — Enterorrhaphy  :     a,  Lembcrt's    suture  ;  b, 
Dupuytren's  suture ;  c,  Cushing's  suture. 


Fig.  152. — Excision  of  Bowel 
with  Enterorrhaphy  and  Stitch- 
ing of  the  Redundant  Mesenterj' : 
second  step. 


Fig    143  — L7ern>\  Method  of  Tendon-suture. 


Fig.  151. — Pylorectomy.  Fig.  154. — Gastro-enterostomy       Fig.  155.— Gastro-enter- 


fafter  Wolfler). 


ostomy  (after  Kocher). 


Fig.  156.— Senn's    Entero-anastomosis  :    a,    Senn's   bone  Fig.    157. — Inguinal   Colos- 

plate;  b,  intestinal  anastomosis  ;  c,  operation  complete.  tomy  (after  Maydl). 

{Frotn  Estnarch  and  Kowalzig.) 


634  A    MANUAL    OF  SURGERY. 

suture  invaginates  serous  membrane  against  serous  mem- 
brane. Senn  modifies  this  by  the  use  of  a  ring.  Wolflers 
suture  unites  the  broad  layers  of  the  serous  coat,  the  knots 
being  tied  internally  (Fig.  150).  Senn  says  that  after  suturing 
a  large  wound  of  the  stomach  or  of  intestine  a  strip  of  omen- 
tum ought  to  be  laid  over  the  wound  and  fastened  by  catgut 
sutures  (omental  graft).  These  grafts  adhere  and  are  a  safe- 
guard against  leakage. 

Pylorectomy  (Excision  of  the  Pylorus). — For  one  week 
before  any  operation  upon  the  stomach,  feed  the  patient  upon 
peptonized  milk  by  the  stomach  and  by  nutritive  enemata, 
and  during  this  period  wash  out  the  stomach  once  a  day 
with  warm  water  introduced  and  withdrawn  by  a  siphon- 
tube.  A  few  hours  before  the  operation,  wash  out  the 
stomach  again.  The  best  incision  through  the  abdominal 
wall  is  transverse  over  the  middle  of  the  tumor.  A  small 
incision  is  made  first  to  permit  of  exploration,  and  if  the 
growth  is  found  to  be  removable,  the  incision  is  enlarged. 
The  centre  of  the  incision  is  over  the  most  prominent  part 
of  the  tumor,  and  the  direction  of  the  incision  corresponds 
with  the  long  axis  of  the  pylorus.  Draw  the  tumor  into  the 
wound,  and  tuck  pads  about  the  stomach  and  the  pylorus  to 
catch  extravasated  fluids.  Free  the  pylorus ;  incise  between 
forceps  the  great  omentum  near  the  greater  curvature  of  the 
stomach,  and  ligate  each  end  in  segments;  treat  the  lesser 
omentum  in  the  same  manner.  The  greater  and  the  lesser 
omentum  are  divided  only  to  an  extent  sufficient  to  permit 
removal  of  the  growth.  Repack  the  gauze  pads  and  tie  a 
rubber  tube  around  the  duodenum  below  the  growth.  In 
making  the  excision  remember  that  the  stomach-wound 
will  be  much  larger  than  the  duodenal  wound,  and  a  special 
method  of  suturing  will  be  required  to  approximate  the  two 
wounds  in  size.  The  lines  of  incision  are  shown  in  Figure 
151.     The  stomach  is  cut  with  scissors  until  two-thirds  of 


DISEASES  AND   INJURIES   OF   THE  ABDOMEN.       635 

its  depth  is  divided,  and  the  organ  is  washed  out.  After 
stopping  hemorrhage  this  cut  is  closed  by  a  continuous 
suture  for  the  mucous  membrane  and  by  interrupted  Lem- 
bert  sutures  for  the  serous  coat.  The  remaining  portion  of 
the  stomach  is  cut  through.  The  duodenum  is  cut  through 
its  upper  half  below  the  growth,  and  is  fastened  to  the 
stomach  by  Lembert  sutures  at  the  upper  border  and  Wolf- 
ler's  sutures  at  the  posterior  borders.  Wolfler's  sutures  are 
applied  from  inside,  pierce  all  the  coats,  and  bring  broad 
layers  of  the  serous  coat  into  apposition.  The  remainder 
of  the  duodenum  is  cut  through,  and  its  anterior  and  inferior 
parts  are  united  to  the  stomach  by  a  double  row  of  sutures, 
as  set  forth  above  (Fig.  151).  Stitch  the  edges  of  the  cut 
omenta  to  the  stomach,  cleanse  the  parts,  replace  the  stom- 
ach, close  the  abdominal  incision,  and  dress  the  wound. 
Give  nothing  by  the  mouth  for  twenty-four  hours.  Thirst 
can  be  relieved  by  enemata  of  water  or  by  the  hypodermatic 
injection  of  boiled  water.  After  twenty-four  hours  begin 
with  stomach-feeding,  starting  with  dessertspoonful-doses 
of  peptonized  milk  every  hour. 

Gastrostomy. — In  Witzel's  method  an  incision  is  made 
four  inches  long,  running  to  the  left  from  the  middle  line, 
just  below  the  border  of  the  ribs.  After  opening  the  peri- 
toneal cavity  seize  the  stomach,  bring  it  out  of  the  wound, 
and  pack  gauze  around  it.  Introduce  a  rubber  tube  into 
the  stomach  and  enfold  it  by  a  double  row  of  Lembert 
sutures.  This  tube  should  be  five  inches  long  and  of  the 
same  diameter  as  a  No.  25  French  bougie.  The  opening 
in  the  stomach  is  toward  the  cardiac  extremity,  the  tube 
is  placed  parallel  w^ith  the  belly-wound,  and  the  outer  end 
of  the  tube  emerges  in  the  median  line.  The  stomach  is 
returned,  and  is  stitched  by  three  sutures  to  the  abdominal 
wall.  The  tube  is  retained  in  place  by  a  catgut  stitch 
through  tb^  wall  of  the  tube  and  the  stomach-wall.     The 


636  A   MANUAL    OF  SURGERY. 

abdominal  incision  is  sutured  and  a  clamp  is  placed  on  the 
tube. 

Gastro-enterostomy  (Senn's  method)  is  the  establish- 
ment of  a  permanent  fistula  between  the  stomach  and  the 
small  intestine,  in  order  to  side-track  the  pylorus.  The 
stomach  is  irrigated  as  before  pylorectomy.  In  the  operation 
of  gastro-enterostomy  a  median  incision  is  made  through  the 
abdominal  wall,  from  below  the  xiphoid  cartilage  to  the 
umbilicus.  An  opening  is  made  in  the  stomach,  in  the  direc- 
tion of  the  long  axis  of  the  viscus,  and  its  edges  are  stitched 
with  a  continuous  catgut  suture.  The  contents  of  the  bowel 
are  forced  along  to  below  the  point  where  an  incision  is  to 
be  made;  a  rubber  tube  is  fastened  around  the  bowel  above 
this  point,  and  another  below  it ;  an  incision  is  made  in  the 
long  axis  of  the  bowel,  and  the  margins  of  the  wound  are 
sutured  in  the  same  manner  as  the  stomach-wound.  Bone 
plates  are  introduced  into  the  stomach  and  intestine,  and  the 
ligatures  are  tied  as  in  intestinal  anastomosis  (p.  637).  Cat- 
gut rings  or  rubber  rings  may  be  used.  Figure  154  shows 
the  result  of  a  gastro-enterostomy,  and  Figure  155  shows 
Kocher's  method  of  gastro-enterostomy  without  rings. 

Enterectomy,  or  Resection  of  the  Intestine :  Enterec- 
tomy  with  Circular  Suturing. — After  opening  the  abdomen, 
isolate  the  loop  of  intestine  it  is  intended  to  resect.  Push  a  rub- 
ber tube  through  the  mesentery,  close  to  the  bowel,  above  the 
seat  of  operation,  and  pass  a  rubber  tube  through  the  mesen- 
tery below  the  seat  of  operation.  Empty  this  segment  of 
bowel  by  squeezing  and  stroking,  tighten  the  rubber  tubes, 
and  clamp  them  to  keep  the  bowel  empty.  Instead  of  tubes, 
strips  of  iodoform  gauze  may  be  used  to  encircle  the  bowel. 
The  diseased  intestine  is  resected,  each  incision  being  carried 
through  a  healthy  segment.  The  lumen  of  each  end  of  the 
divided  gut  is  irrigated  with  boiled  water.  The  divided  sur- 
faces are  approximated  by  a  double  row  of  sutures — a  con- 


DISEASES  AXD   IXJURIES   OF  THE  ABDOMEN.       637 

tinuous  suture  for  the  mucous  membrane,  and  Lembert's, 
Dupuytren's,  or  Cushing's  suture  for  the  serous  coat.  If  a 
redundant  fold  of  mesentery  is  left,  it  can  be  stitched  at  its 
raw  edge.  Many  surgeons  remove  a  V-shaped  piece  of  mes- 
entery and  tie  the  mesenteric  vessels.  The  tubes  are  removed 
and  the  wound  is  cleansed,  closed,  and  dressed.  Figure  153 
shows  the  tubes  fastened  for  excision  of  the  bowel,  and 
Figure  152  shows  enterorrhaphy  with  stitching  of  the  re- 
dundant mesentery. 

If  the  two  segments  of  bowel  are  unequal  in  size,  the 
narrower  part  of  the  bowel  should  be  cut  obliquely  and 
the  larger  part  should  be  cut  transversely.  To  meet  this 
complication  Billroth  devised  lateral  implantation.  Suppose 
the  caecum  has  been  resected :  its  lower  end  is  closed  by 
Lembert  sutures,  an  opening  is  made  in  the  long  axis  of  the 
periphery  of  the  colon  opposite  the  mesocolon  attachment, 
and  the  end  of  the  ileum  is  sutured  into  this  incision. 

Senn  advises  the  insertion  of  an  anastomosis-ring  in  the 
ileum,  the  invagination  of  the  colon  as  the  ring  is  pulled  into 
place,  and  the  firm  suturing  of  the  ring.  By  Senn's  method 
the  ileum  may  be  implanted  into  the  end  of  the  colon  or  into 
a  slit  in  the  wall  of  a  large  bowel  after  the  end  of  the  colon 
has  been  closed.  In  some  cases,  where  one  portion  of  bowel 
is  larger  than  the  other,  intestinal  anastomosis  is  the  prefer- 
able method.  For  a  full  week  after  an  intestinal  resection  the 
patient  is  fed  chiefly  by  nutrient  enemata.  During  the  first 
ttv'enty-four  hours  nothing  is  given  by  the  stomach  but  bits 
of  ice,  and  for  the  next  six  days  but  a  very  little  liquid  food 
is  allowed  to  be  swallowed. 

Intestinal  Anastomosis. — Operation  with  Rings. — In  this 
operation  a  portion  of  bowel  above  the  obstruction  and  a 
loop  below  the  obstruction  are  brought  into  the  wound. 
These  segments  are  emptied,  and  are  kept  empty  by  the 
fastening  around  them  of  rubber  tubes  or  of  iodoform  strips. 


638 


A   MANUAL    OF  SURGERY. 


Two  tubes  are  needed  for  each  loop  of  bowel.  Pack  in 
gauze  pads.  Make  an  incision  in  one  loop,  in  the  long  axis 
of  the  bowel,  on  the  surface  away  from  the  mesentery ;  per- 
mit the  contents  to  escape  externally ;  irrigate  this  segment 
with  boiled  water ;  and  introduce  the  bone  plate  of  Senn 
(Fig.  156,  a)  or  Abbe's  catgut  ring.  A  calyx-eyed  needle  is 
used  (Fig.  147),  and  the  threads  of  the  ring  are  carried 
through  the  coats  of  the  bowel  and  are  gathered  together  in 
the  bite  of  a  pair  of  forceps. 
The  other  loop  of  intestine  is 
treated  in  a  similar  manner. 
The  intestines  are  so  brought 
together  that  the  two  wounds 
are  opposite  each  other,  the 
posterior  sutures  being  first 
tied,  next  the  upper,  next  the 
lower,  and  finally  the  ante- 
rior threads.  The  ends  of  the 
threads  are  cut  off  and  the 
entire  anastomosis  is  sur- 
rounded by  a  layer  of  Lem- 
bert  sutures  or  is  encircled 
by  Cushing's  suture.  Figure 
156,  B,  shows  an  intestinal 
anastomosis  partly  finished,  and  Figure  156,  c,  shows  an  anas- 
tomosis complete.  Figure  158  shows  the  passing  of  the 
sutures  when  the  catgut  ring  of  Abbe  is  employed. 

Many  surgeons  are  returning  to  anastomosis  without  rings 
in  cases  of  resection.  Abbe's  method  is  as  follows  :  After 
closing  the  ends  he  places  them  side  by  side  and  applies  two 
rows  of  a  Dupuytren  suture,  one-quarter  of  an  inch  apart. 
These  rows  of  sutures  are  an  inch  longer  than  the  slit  in  the 
bowel  will  be  (Fig.  159),  the  thread  at  the  end  of  each  row 
being  left  long.     An   incision  is   made  in  the  bowel,   one- 


FiG.  158. — Method  of  Passing  the  Silk  Su- 
tures in  Inserting  the  Rings  of  Abbe. 


DISEASES  AjYD   injuries   OF   THE  ABDOMEN.       639 


quarter  of  an  inch  from  the  sutures,  both  rows  of  threads 
being  on  the  same  side  of  the  cut.  This  incision  is  four 
inches  long.  The  other  portion  of  bowel  is  then  incised  in 
the  same  way.  The  adjacent  cut-edges  are  united  by  a 
whip^stitch  which  goes  through  all  the  coats,  and  the  free 

cut-edges  are  stitched 
in  the  same  manner 
(Fig.  160).  The  sur- 
geon now  utilizes  the 
long  threads  of  the  first 
sutures,  and  brings  the 
serous  surfaces  of  the 
opposite  sides  together 

Fig.   159.— Suturing  Intestines  in  Apposition  before    Oy     mcanS     OI      Uupuy- 
Incision  (Abbe).  ^^.^^^'3    guturC. 

Murphy's  button  is 
a  mechanical  arrange- 
ment by  which  an  anas- 
tomosis is  rapidly  per- 
formed, the  two  seg- 
ments being  clamped 
together.  For  anasto- 
mosis  below  the    ileo- 

FiG.  160.— Showing  the  Four-inch  Incision  and  the   p-ppql       valve     a      1  a  r  o"  e 
Sewing  of  the  Edges  (Abbe).  ^ 

Murphy  button  does 
admirably,  but  for  anastomosis  higher  up  so  small  a  button 
must  be  used  that  the  result  is  unsatisfactory. 

Inguinal  Colostomy. — MaydVs  Operation. — In  this  opera- 
tion a  vertical  incision  four  inches  long  is  made  over  the  por- 
tion of  colon  to  be  incised.  The  colon  usually  bulges  into 
the  wound,  but  if.it  does  not  it  may  easily  be  found  by  follow- 
ing with  the  finger  the  parietal  peritoneum  outward,  back- 
ward, and  inward,  the  first  obstruction  it  encounters  being' 
the  mesocolon.     Draw  the  colon  out  of  the  wound  until  its 


640  A   MANUAL    OF  SURGERY. 

mesenteric  attachment  is  level  with  the  abdominal  incision. 
Push  a  glass  bar  through  a  slit  in  the  mesocolon  near  the 
bowel,  and  wrap  the  ends  of  the  bar  with  iodoform  gauze  to 
prevent  slipping.  The  two  parts  of  the  flexure  are  stitched 
together  by  sutures  which  penetrate  the  serous  and  muscular 
coats  (Fig.  157).  If  the  colon  has  to  be  opened  immediately, 
stitch  the  serous  coat  of  the  bowel  to  the  parietal  peritoneum 
before  opening.  Whenever  possible,  wait  from  twelve  to 
twenty-four  hours  before  opening.  The  colon  is  opened  by 
the  cautery  or  by  scissors.  If  the  artificial  anus  is  to  be 
permanent,  make  a  transverse  incision  three-quarters  of  the 
way  through  the  bowel.  The  bar  is  withdrawn  in  a  few 
days,  and  the  bowel  retracts.  If  the  artificial  anus  is  to  be 
temporary,  the  incision  is  longitudinal.  This  operation  has 
great  advantages  :  it  is  quick,  certain,  reasonably  safe,  and 
entirely  prevents  fecal  accumulation  below  the  opening. 
The  old  operation  of  lumbar  colostomy  is  now  rarely  per- 
formed. Some  surgeons  cut  one-fourth  way  through  the 
colon  when  it  is  first  opened,  and  entirely  across  in  two  or 
three  weeks. 

Abdominal  Hernia  or  Rupture. — This  condition  is  the 
protrusion  of  a  viscus  or  part  of  a  viscus  from  the  abdominal 
cavity.  MacCormac  says  the  term  implies  that  the  pro- 
truded viscus  is  covered  with  integument ;  hence  a  protrusion 
of  viscera  through  a  wound  does  not  constitute  a  hernia.  A 
hernia  has  three  parts — the  sac,  the  sac-contents,  and  the 
sac-coverings.  The  sac  is  formed  of  peritoneum.  A  con- 
genital sac  is  due  to  developmental  defect,  and  is  found  only 
in  the  inguinal  region  or  in  the  umbilicus.  An  acquired  sac 
is  due  to  intra-abdominal  pressure  bulging  the  peritoneal 
covering  of  the  internal  abdominal  ring  and  converting  it 
into  a  pouch.  The  sac  comprises  a  body,  a  neck,  and  a 
•mouth.  A  sac  once  formed  is  almost  certain  to  persist, 
because  it  adheres  by  its  outer  surface  to  surrounding  parts, 


DISEASES  AND   INJURIES    OF   THE  ABDOMEN.       64 1 

and  hence  the  sac  of  a  hernia  is  irreducible  even  when  the  con- 
tents are  reducible.  The  neck  of  the  sac  is  due  to  the  con- 
striction through  which  the  sac  passes ;  it  becomes  furrowed 
and  folded,  and  the  adhesion  of  these  folds  causes  thickening 
and  rigidity.  Hernia  of  the  bladder  or  of  the  caicuni  has  no 
sac  or  but  a  partial  sac.  The  contents  of  the  sac  depend  chiefly 
on  the  situation,  a  portion  of  the  ileum  being  the  usual  con- 
tents. The  colon,  the  stomach,  the  great  omentum,  and 
other  structures  may  enter  the  hernial  sac.  An  enterocele 
contains  only  intestine  ;  an  epiplocele  contains  only  omentum  ; 
an  entero-cpiplocclc  contains  both  omentum  and  intestine ;  a 
cystocelc  contains  a  portion  of  the  bladder.  The  coverings 
of  the  sac,  which  vary  with  its  situation,  will  be  set  forth 
during  the  consideration  of  special  herniae.  In  old  herniae 
the  layers  are  never  distinct,  fat  and  muscle  waste,  tissues 
adhere,  and  the  skin  stretches  and  atrophies. 

Causes  of  Hernia. — The  male  sex  is  more  liable  to  hernia. 
It  occurs  at  all  periods  of  life,  and  hereditary  predisposition 
sometimes  seems  to  exist.  Excessive  length  of  the  mesen- 
tery has  been  assigned  as  a  cause.  Any  laborious  occupa- 
tion predisposes  to  rupture.  Any  condition  which  weakens 
the  abdominal  wall  predisposes  (muscular  relaxation  from 
ill-health,  relaxation  of  abdominal  walls  following  the  termi- 
nation of  pregnancy,  the  removal  of  a  large  tumor,  or  the 
tapping  of  an  ascites,  and  wounds  or  abscesses  of  the  ab- 
dominal wall).  The  exciting  cause  is  muscular  effort  (strain- 
ing at  stool,  coughing,  lifting  weights,  jumping,  straining  to 
make  water,  and  the  sexual  act).  All  congenital  herniae  are 
due  to  structural  defects.  Hernia  is  divided  clinically  into 
reducible,  irreducible,  incarcerated,  inflamed,  and  strangidated. 

Reducible  Hernia. — In  this  form  of  hernia  the  contents 
of  the  sac  can  be  reduced  into  the  abdominal  cavity.  At  a 
known  hernial  opening  the  patient  has  a  smooth  enlargement 
(narrower  above  than    below)    which   began  to  grow  from 

41 


642  A   MAJVUAL    OF  SUKGEKV. 

above  and  extended  downward.  A  distinct  neck  can  often 
be  felt.  In  enterocele,  straining,  lifting,  or  standing  enlarges 
the  mass ;  the  tumor  becomes  smaller  and  may  disappear  on 
lying  down  ;  cough  causes  impulse  or  succussion  ;  the  tumor 
is  elastic,  and  on  reduction  there  is  a  gurgling  sound.  In 
epiplocele  the  mass  is  often  irregular  and  compressible,  and 
feels  boggy  rather  than  elastic ;  muscular  effort  does  not 
have  much  influence  in  enlarging  it;  impulse  on  coughing 
is  slight ;  percussion  gives  a  dull  note,  and  reduction  pro- 
duces no  gurgling  sound.  In  entero-epiplocele  some  parts 
of  the  tumor  are  smooth,  elastic,  and  tympanitic,  others  are 
dull  on  percussion,  irregular,  and  flabby ;  but  the  diagnosis 
of  this  especial  form  is  uncertain.  The  victims  of  reducible 
hernia  complain  of  some  pain  on  exertion,  of  dyspepsia,  and 
often  of  constipation. 

Treatnie7it  of  Reducible  Hernia :  Palliative  Treatment. — 
Prevent  constipation,  forbid  sudden  strains  and  violent  exer- 
cise, and  Order  a  truss.  The  continued  employment  of  a 
truss,  especially  in  young  persons,  may  bring  about  a  cure. 
The  day  truss  should  be  applied  before  rising  in  the  morn- 
ing and  be  removed  after  lying  down  at  night,  when  a  light 
truss  should  be  substituted.  A  special  truss  is  applied  for 
bathing.  In  very  fat  people  there  is  always  trouble  in 
adjusting  a  truss.  A  femoral  hernia  is  more  difficult  to  keep 
reduced  than  an  inguinal  hernia.  In  those  cases  in  which 
the  gut  is  replaceable,  but  a  portion  of  omentum  is  irre- 
ducible, it  is  difficult  to  maintain  reduction  with  a  truss. 
In  an  oblique  inguinal  hernia  the  pad  of  the  truss  fits  over 
the  internal  abdominal  ring ;  in  a  direct  inguinal  hernia, 
over  the  external  abdominal  ring ;  in  a  femoral  hernia,  over 
the  femoral  ring  at  the  level  of  Gimbernat's  ligament. 
MacCormac's  rule  to  measure  for  a  truss  is  as  follows :  In 
either  inguinal  or  femoral  hernia,  start  the  tape  from  the 
lower  part  of  the  hernial  opening,  carry  it  up  to  the  anterior 


DISEASES  AND   INJURIES   OF   THE  ABDOMEN.      643 

superior  iliac  spine  of  the  same  side,  then  take  it  around  the 
bod}-,  one  inch  below  the  crest  of  the  ilium,  to  the  other 
anterior  superior  iliac  spine,  and  then  to  the  upper  part  of 
the  hernial  opening."^  A  well-fitting  truss  will  keep  up  the 
hernia  even  when  the  patient  sits  in  a  position  to  relax  the 
abdominal  walls  and  then  coughs  and  strains.  A  truss  is 
always  uncomfortable  at  first,  but  a  person  soon  grows  used 
to  it.  It  should  be  kept  scrupulously  clean,  and  it  is  well 
to  dust  borated-talc  powder  upon  the  skin  under  the  pad 
at  least  once  a  day.  A  truss  which  does  not  keep  up  the 
hernia  or  which  causes  pain  does  harm.  Too  strong  a  spring 
tends  to  enlarge  the  hernial  orifice,  and  thus  aggravates  the 
case.  Bryant  insists  that  even  after  an  apparent  cure  with 
a  truss  the  instrument  must  be  worn  for  a  long  time. 

Radical  trcatnunt  seeks  to  permanently  cure  b}'  plugging 
the  mouth  of  the  sac  or  by  obliterating  the  canal  of  descent. 
Radical  operations  should  be  performed  when  strangulation 
is  operated  for,  in  ordinary  cases  of  reducible  hernia  in  which 
a  truss  is  very  painful  or  does  not  keep  up  the  bowel,  in 
most  cases  of  irreducible  hernia,  and  in  any  case  which  has 
occasional  attacks  of  obstruction.  Radical  cures  fail  if  the 
subject  is  under  three  years  of  age. 

Macewcns  Operatio7i  for  Inguinal  Hernia. — The  instru- 
ments required  in  this  operation  are  scalpels,  a  blunt  straight 
bistoury,  a  dry  dissector,  a  grooved  director,  scissors,  a 
hernia- director,  hernia-needles  (Fig.  164),  dissecting-forceps, 
toothed  forceps,  haemostatic  forceps,  an  aneurysm-needle, 
blunt  hooks,  half-curved  needles,  needle-holder,  and  catgut 
sutures.  The  patient  lies  recumbent,  the  thigh  being  ab- 
ducted and  partly  flexed  and  resting  on  a  pillow  beneath  the 
knee.  The  bowel  is  reduced,  and  an  incision  three  inches 
lone  is  made  in  the  direction  of  the  inguinal  canal,  the 
centre  of  the  incision   corresponding  to  the   external  ring. 

^  Treves's  JMamial  of  Surgery,  "Hernia." 


644  ^   MANUAL    OF  SURGERY. 

The  sac  is  freed  from  its  attachments  below  and  is  Hfted  up. 
The  surgeon  introduces  a  finger  into  the  inguinal  canal  and 
separates  the  sac  from  the  cord  and  from  the  walls  of  the 
canal,  and  then  carries  the  finger  through  the  internal  ring 
and  separates  the  peritoneum  for  one  inch  about  the  periph- 
ery of  this  aperture  (Fig.  1 6 1,  a),  a  catgut  stitch  is  fastened  to 
the  lowest  portion  of  the  sac,  and  is  passed  through  the  sac 
several  times,  so  that  pulling  on  the  stitch  will  purse  up  the 
sac  (Fig.  i6i ,  b).  The  free  end  of  this  stitch  is  carried  through 
the  internal  ring  into  the  belly,  and  is  pushed  out  through 
abdominal  muscles  one  inch  above  the  internal  ring,  the 
skin  being  pushed  aside  so  as  to  escape  perforation  by  the 
needle.  The  thread  is  tightened  so  as  to  fold  up  the  sac 
and  pull  it  into  the  belly.  This  plugs  the  ring  (Fig.  i6i,c,  d). 
The  thread  is  handed  to  an  assistant  to  keep  tight  until  the 
sutures  are  introduced  into  the  ring,  when  the  sac  is  perma- 
nently anchored  by  taking  several  stitches  in  the  external 
oblique  muscle.  A  strong  catgut  suture  is  passed  with  a 
Macewen  needle  through  the  conjoined  tendon  from  below 
upward,  the  ends  of  this  suture  being  carried  through 
Poupart's  ligament  and  the  outer  borders  of  the  internal 
ring  from  within  outward.  This  suture  is  tightened  and 
closes  the  internal  ring.  The  external  ring  is  sutured  and 
the  skin  is  stitched  together  (Fig.  i6i,e). 

In  congenital  hernia  the  sac  is  divided  in  its  middle  and 
the  lower  part  is  closed  by  stitches,  forming  a  tunica  vagi- 
nalis. The  upper  part  of  the  sac  is  slit  posteriorly  to  per- 
mit the  escape  of  the  cord,  and  is  closed  by  stitches.  The 
operation  is  finished  as  in  the  acquired  form  (Fig.  162). 
After  this  operation  the  patient  should  stay  in  bed  for  six 
or  seven  weeks,  and  must  not  walk  for  eight  or  nine  weeks. 
Workmen  after  this  operation  should  always  wear  a  pad  and 
a  spica  bandage.  Children  require  no  pad.  Never  apply  a 
truss,  as  strong  pressure  will  atrophy  the  curative  scar. 


DISEASES  AND  INJURIES   OF   THE  ABDOMEN.      645 


Fig.  161,  A-E. — Macewen's  Operation  for  the  Radical  Cure  Fig.  162. — Macewen's  Ope- 

of  Inguinal  Hernia :  A,  Stripping  of  the  sac;  b,  Purse-string  ration  for  the  Radical  Cure 

suture;    c.  Fastening   the   purse-string  suture;    d,  Passing,  of  Congenital  Hernia, 
and  E,  tying,  the  sutures  for  the  internal  ring. 
/  .^- 


FiG.  163. — Herniotomy  in  Inguinal  Hernia. 
A 


FiG.  164. — A,  Hernia-needles  ;  b,  Hinged        Fig.  165,  a-c. — Bassini's  Operation  for  the 
Hernia-director.  Cure  of  Inguinal  Hernia. 

iFroin  Esmarch  and  Kowalzig.) 


646  A   MANUAL    OF  SURGERY. 

BassinVs  Operation  for  Inguinal  Hernia. — This  operation 
forms  a  new  inguinal  canal.  The  instruments  employed 
are  the  same  as  for  Macewen's  operation,  excepting  special 
needles,  which  are  not  needed.  The  position  is  the  same 
as  in  Macewen's  operation.  An  incision  is  made  from  the 
external  ring  to  a  point  external  to  the  internal  ring. 
The  sac  is  exposed  and  twisted,  its  neck  is  ligated,  and 
it  is  cut  off  in  front  of  the  ligature.  The  spermatic  cord 
is  lifted  (Fig.  165,  a);  the  border  of  the  rectus  muscle,  the 
edges  of  the  internal  oblique  and  the  transversalis  muscles, 
and  the  transversalis  fascia,  are  sutured  to  Poupart's  liga- 
ment below  the  cord  (Fig.  165,  b).  The  border  of  the  external 
oblique  is  sutured  to  Poupart's  ligament  above  the  cord 
(Fig.  165,  c).  The  skin  is  sutured.  Halstead  makes  a  new 
inguinal  canal  and  a  new  ring,  and  places  the  cord  between 
the  external  oblique  muscle  and  the  integument  in  preference 
to  placing  it,  as  does  Bassini,  below  the  external  oblique. 

Radical  Cure  of  Umbilical  Hernia. — Cut  out  the  umbilicus 
(omphalectomy)  and  approximate  the  edges. 

Radical  Cure  vf  Femoral  Hernia. — Salzer  stitches  Pou- 
part's ligament  to  the  pectineal  fascia.  Cheyne  ligates  the 
neck  of  the  sac,  stitches  the  stump  to  the  abdominal  wall, 
dissects  out  a  flap  from  the  pectineus  muscle,  stitches  this 
flap  to  Poupart's  ligament  and  to  the  abdominal  wall,  and 
thus  fills  up  the  crural  canal.  Bassini  makes  an  incision 
parallel  with  Poupart's  ligament,  ties  the  neck  of  the  sac, 
cuts  below  the  ligature,  and  returns  the  stump  into  the  belly. 
He  attaches  by  deep  sutures  Poupart's  ligament  to  the  pecti- 
neal aponeurosis  as  high  up  as  the  pectineal  eminence,  the 
cord  or  round  ligament  being  drawn  out  of  the  way.  Super- 
ficial sutures  are  passed  between  the  pubic  portion  and  the 
iliac  portion  of  the  fascia  lata. 

Irreducible  Hernia. — The  tumor  in  irreducible  rupture 
presents  the  usual  evidences  of  hernia,  shows  an  impulse  on 


DISEASES  AND   INJURIES   OE   THE  ABDOMEN      647 

coughing,  but  cannot  be  replaced  in  the  abdomen.  Some- 
times a  portion  is  reducible  and  a  portion  is  irreducible.  A 
hernia  may  become  irreducible  because  of  the  size  of  the 
mass,  because  of  adhesions,  or  because  of  a  great  growth  of 
omental  fat.  An  irreducible  hernia  is  liable  to  be  bruised 
and  to  cause  much  distress  and  pain,  and  is  always  a  menace 
to  life  because  of  the  danger  of  obstruction  and  strangulation. 
A  small  irreducible  hernia  can  be  supported  by  a  hollow 
padded  truss ;  a  large  hernia  of  this  variety  is  carried  in  a 
bag-truss.  The  patient  must  not  take  very  active  exer- 
cise, must  keep  the  bowels  regular,  and  must  live  upon 
a  plain  diet.  Most  of  these  cases  should  be  treated  by 
operation. 

Incarcerated  or  Obstructed  Hernia. — Obstruction  takes 
place  by  the  damming  up  of  feces  or  of  undigested  food, 
the  fecal  current  being  arrested,  but  the  blood-current  in 
the  walls  of  the  bowel  being  undisturbed.  Incarceration 
is  commonest  in  irreducible  hernia,  umbilical  hernia,  and 
during  the  existence  of  constipation.  The  tumor  enlarges 
and  becomes  tender,  painful,  and  dull  on  percussion ;  pres- 
sure diminishes  it  in  size ;  it  is  irreducible,  but  still  pre- 
sents impulse  on  coughing.  The  abdomen  is  somewhat 
distended  and  painful ;  there  are  nausea,  constipation,  and 
not  unusually  slight  vomiting.  Constitutional  disturbance 
is  slight  and  constipation  is  not  absolute,  wind  at  least 
usually  passing.  Vomiting  is  not  fecal.  The  treatment  is 
rest  in  bed  in  a  position  to  relax  the  belly,  an  ice-bag  over 
the  hernia,  and  a  little  opium  for  pain.  Do  not  give  a 
particle  of  food  for  twenty-four  hours;  when  the  active 
symptoms  subside  give  an  enema,  and  after  this  acts  a  dose 
of  castor  oil.  Do  not  employ  taxis,  as  bruising  the  bowel 
may  produce  strangulation. 

Inflamed  Hernia. — Inflammation  of  a  hernia  is  local  peri- 
tonitis  due  to  injury  of  an  irreducible   hernia.     The   mass 


648  A   MANUAL    OF  SURGERY. 

becomes  tender,  painful,  and  hot.  In  enterocele  much  fluid 
forms  ;  in  epiplocele  the  mass  becomes  hard.  The  hernia 
cannot  be  reduced;  there  is  constipation,  often  vomiting, 
usually  fever,  but  the  mass  still  shows  impulse  on  coughing. 
Vomiting  is  not  fecal.  Some  wind  is  usually  passed  by  the 
bowels.  Constitutional  symptoms  are  slight.  The  treatment 
is  rest  in  bed  with  abdominal  relaxation,  an  ice-bag  to  the 
tumor,  a  small  amount  of  opium  by  the  mouth  if  pain  is 
severe,  an  enema,  and  when  this  acts  a  saline.  If  pus  forms, 
incise  and  drain. 

Strangulated  hernia  is  a  condition  in  which  not  .only  is  the 
fecal  circulation  arrested,  but  the  circulation  of  blood  in  the 
bowel-wall  is  also  arrested.  The  bowel  is  irreducible  and 
obstructed,  and  the  blood  ceases  to  circulate.  Strangulation 
is  commonest  in  old  inguinal  ruptures  in  active,  middle-aged 
men,  and  is  more  frequent  in  enteroceles  than  in  epiploceles. 
It  may  be  due  to  entry  into  the  sac  of  more  intestine  or 
omentum,  which  has  been  forced  down  by  sudden  movement 
or  violent  effort.  It  may  be  due  to  active  peristalsis  or  to 
congestion,  and  it  may  arise  from  inflammation  or  from  in- 
carceration. The  constriction  is  usually  at  the  neck  of  the 
sac,  in  the  outside  tissues,  or  even  in  the  sac  itself  In  an 
hour-glass  hernia  the  constriction  is  in  the  body  of  the  sac. 
Adhesions  within  the  sac  may  cause  strangulation.  Spas- 
modic contraction  of  the  tissues  about  the  neck  of  the  sac 
is  an  exploded  hypothesis.  When  strangulation  once  begins 
the  hernia  swells,  a  furrow  forms  at  the  seat  of  constriction, 
the  bowel  and  omentum  below  the  constriction  become  deeply 
congested  and  oedematous,  and,  finally,  the  rupture  passes 
into  a  state  of  moist  gangrene.  The  sac  is  apt  to  inflame,  and 
inflammation  produces  fluid  and  lymph  ;  serum  accumulates 
in  the  sac,  being  first  clear,  then  bloody,  and  finally  brown 
and  foul.  When  gangrene  is  once  established  the  bowel  is 
in    danger   of   rupturing.      A   strangulated   femoral   hernia 


DISEASES  AND   INJURIES   OF   THE   ABDOMEN.       649 

becomes  gangrenous  more  rapidly  than  does  a  strangulated 
inguinal  hernia. 

Syiuptoiiis.- — The  hernia  is  found  to  be  irreducible ;  it 
becomes  larger,  tender,  painful,  and  dull  on  percussion, 
and  gives  no  impulse  on  coughing.  Abdominal  pains, 
uncontrollable  vomiting,  and  prostration  come  on.  The 
vomiting  is  first  of  the  contents  of  the  stomach,  next  of 
bilious  matter,  but  finally  of  feces.  Constipation  is  abso- 
lute, no  wind  even  being  passed,  though  in  the  very  begin- 
ning there  may  be  some  diarrhoeal  passages  from  below  the 
constriction.  The  urine  is  scanty  and  high-colored,  and 
contains  only  a  small  amount  of  the  chlorides ;  the  tongue 
becomes  dry  and  brown ;  the  thirst  is  torturing ;  the  pulse 
is  small  and  very  rapid.  Pains  in  the  abdomen  and  in  the 
hernia  become  violent,  and  collapse  rapidly  develops.  When 
gangrene  begins,  the  symptoms  apparently  lessen  in  violence  : 
there  is  a  "delusive  calm."  Vomiting  usually  ceases,  though 
regurgitation  may  take  its  place ;  hiccough  begins  ;  the  pain 
abates  or  disappears ;  the  pulse  becomes  very  feeble  and 
intermittent;  collapse  deepens,  and  delirium  is  usual.  It  is 
a  safe  clinical  rule  that  in  strangulated  hernia  cessation  of 
pain  without  the  relief  of  constriction  or  the  use  of  opiates 
means  that  gangrene  has  begun.  In  a  pure  omental  hernia 
strangulation  produces  similar  but  less  decided  symptoms. 
In  Littre's  hernia  only  a  portion  of  the  circumference  of  the 
bowel  is  constricted,  usually  in  the  femoral  ring.  In  a 
strangulated  Littre  hernia  constipation  is  rarely  absolute 
and  the  tumor  is  often  undiscovered. 

Treatment.— \x\  treating  strangulated  hernia,  place  the 
patient  upon  his  back,  bend  the  knees  over  a  pillow,  and 
rigidly  interdict  the  administration  of  food.  An  attempt  is 
to  be  made  to  effect  reduction  by  gentle  manipulation  or 
taxis.  In  applying  taxis  to  a  femoral  or  inguinal  hernia,  flex 
and  adduct  the  thigh  of  the  affected  side.    In  applying  taxis 


650  A   MANUAL    OF  SURGERY. 

to  an  umbilical  hernia  both  thighs  should  be  flexed  upon 
the  abdomen.  Always  lower  the  shoulders  and  head  and 
raise  the  pelvis,  and  accomplish  this  by  lifting  the  foot 
of  the  bed  and  placing  pillows  under  the  pelvis.  Grasp 
the  neck  of  the  sac  with  the  fingers  and  thumb  of  one 
hand,  and  employ  the  other  hand  to  squeeze  the  hernia  and 
urge  it  toward  the  belly.  In  direct  inguinal  hernia  the 
pressure  should  be  backward  and  a  little  upward ;  in  umbil- 
ical hernia  it  should  be  backward  ;  in  oblique  inguinal  hernia 
it  should  be  upward,  outward,  and  backward  ;  in  femoral 
hernia  it  should  be  downward  until  the  hernia  enters  the 
saphenous  opening,  and  then  *'  backward  toward  the  pubic 
spine  "  (Sir  Wm.  MacCormac).  If  the  bowel  is  reduced,  it 
passes  from  the  hand  with  a  sudden  slip  and  enters  the  belly 
with  an  audible  gurgle ;  omentum,  when  reduced  slowly, 
glides  back  without  gurgling.  Taxis  is  never  to  be  con- 
tinued long,  and  it  is  not  even  to  be  attempted  in  cases  of 
great  acuteness,  in  cases  where  strangulation  has  lasted  for 
several  days,  in  cases  known  to  have  previously  been  irre- 
ducible, in  cases  associated  with  stercoraceous  vomiting,  or 
in  an  inflamed  or  gangrenous  hernia. 

If  taxis  fails,  obtain  the  patient's  permission  to  operate. 
Anaesthetize  ;  try  taxis  again  while  ether  is  being  dropped 
upon  the  hernia  to  cause  cold  ;  if  it  fails,  at  once  perform 
herniotomy.  Taxis  possesses  certain  dangers :  it  may  rup- 
ture the  bowel ;  it  may  rupture  the  neck  of  the  sac  and 
force  the  bowel  through  the  rent ;  it  may  strip  the  peri- 
toneum from  around  the  hernial  orifice  and  force  the  bowel 
between  the  detached  peritoneum  and  the  abdominal  wall ; 
it  may  reduce  a  hernia  into  the  belly  when  the  bowel  is 
still  strangulated  by  adhesions ;  it  may  reduce  the  hernia 
€71  masse  or  e7i  bloc,  the  sac  and  strictured  bowel  being 
forced  together  into  the  abdomen.  By  reduction  ejt  bissac 
is  meant  the  forcing  of  a  congenital  hernia  into  a  congenital 


DISEASES  AND   INJURIES   OE   THE   ABDOMEN.      65 1 

pouch  or  diverticulum.  In  any  of  the  above  accidents 
strangulation  may  persist  after  apparent  reduction  by  taxis, 
and  this  condition  calls  for  instant  laparotomy — in  most 
instances  through  the  hernial  aperture.  If  taxis  is  success- 
ful, put  the  patient  to  bed,  apply  a  pad  and  bandage,  allow 
the  patient  to  take  no  food  until  vomiting  ceases,  merely 
permitting  him  to  suck  bits  of  ice,  keep  him  on  a  liquid  diet 
for  several  days,  and  stop  peristalsis  by  opium.  At  the  end 
of  the  first  week  give  solid  food  ;  if  the  bowels  have  not  acted 
by  this  time,  administer  an  enema,  following  it  by  a  dose  of 
Epsom  salt  if  there  is  no  pain  or  no  disposition  to  vomit. 
Some  surgeons  advocate  inversion  as  a  valuable  aid  to  taxis. 
Herniotomy. — The  instruments  required  in  herniotomy 
are  a  scalpel,  a  hernia-knife  and  director,  haemostatic  and  dis- 
secting forceps,  blunt  hooks,  scissors,  a  dry  dissector,  partly- 
curved  needles,  and  a  needle-holder.  Drainage-tubes  should 
be  ready.  In  the  operation  the  patient  lies  upon  his  back  with 
the  shoulders  raised,  the  surgeon  standing  upon  the  patient's 
right  side.  In  oblique  inguinal  Jieriiia  a  fold  of  skin  is  raised 
at  right  angles  to  the  axis  of  the  external  ring  and  is  trans- 
fixed, and  the  wound  which  results  is  extended  until  it 
becomes  three  inches  in  length.  The  tissues  are  divided 
until  the  sac  is  reached,  and  no  attempt  is  made  to  specially 
identify  them.  The  sac  is  known  by  the  fat  which  usually 
covers  it,  by  the  arborescent  arrangement  of  its  vessels,  by 
the  fact  that  it  can  be  pinched  up  between  the  finger  and 
thumb  and  the  layers  rolled  over  each  other,  and  by  the 
fluid  within  the  sac.  Should  the  sac  be  opened  ?  In  very 
recent  cases  it  is  usually  unnecessary,  but  if  there  is  any 
doubt  as  to  the  condition  of  the  bowel,  or  if  a  radical  cure 
is  to  be  attempted,  open  the  sac  and  be  certain  as  to  the  con- 
dition of  its  contents.  The  general  rule  should  be  to  open  the 
sac.  The  sac  is  opened  and  the  contents  examined  for  fecal 
odor  (which  is  not  unusual)  and  for  gangrenous  smell ;  the 


652  A   MANUAL    OF  SURGERY. 

thickness  of  the  bowel  is  estimated,  and  the  color  and  lustre 
are  determined.  Always  pull  down  the  bowel  and  examine 
the  seat  of  constriction.  If  the  bowel  is  healthy,  restore  it  and 
do  a  radical  cure.  If  there  is  a  gangrenous  or  a  strongly  fecal 
smell,  wash  the  sac  and  bow^el  with  corrosive-sublimate  solu- 
tion and  fasten  the  bowel  to  the  skin  by  a  couple  of  stitches. 
In  oblique  inguinal  hernia  nick  the  constriction  upward  and 
outward,  as  shown  in  Figure  163.  In  direct  inguinal  hernia 
the  cut  is  made  upward  and  inward.  Do  not  open  the  bowel 
at  this  time,  but  dust  the  parts  with  iodoform  and  dress.  The 
bowel  may  recover  in  a  day  or  two,  when  it  can  be  restored 
to  the  belly  ;  or  it  may  slough  and  form  an  artificial  anus. 
If  gangrene  of  the  bowel  is  pronounced,  resect  the  gangre- 
nous bowel,  and  either  make  an  artificial  anus  or  perform  an 
end-to-end  approximation  or  an  anastomosis.  Gangrenous 
omentum  requires  ligation  and  resection.  If  the  bowel  is  fit 
to  reduce,  push  it  just  inside  the  ring,  irrigate  the  parts, 
insert  a  drain,  and  stitch.  In  many  cases  perform  a  radical 
cure.  \x\  femoral  hernia,  make  the  incision  one  inch  internal 
to,  and  parallel  with,  the  femoral  vessels,  and  crossing  the 
tumor  and  ligament  (Barker).  Divide  the  constriction  by 
cutting  upward  and  a  little  inward.  In  umbilical  hernia 
make  a  slightly  curved  incision  a  little  to  one  side  of  the 
middle  of  the  tumor,  open  the  sac,  separate  adhesions,  and 
divide  the  constriction  by  cutting  upward  or  downward,  and 
sometimes  also  laterally. 

After  an  operation  for  strangulated  hernia,  put  the  patient 
to  bed ;  bend  the  knees  over  a  pillow ;  give  no  food  by  the 
mouth  for  thirty-six  hours  (MacCormac),  only  allowing  the 
patient  bits  of  ice  to  suck;  give  nutrient  enemata  containing 
brandy;  and  use  morphia  hypodermatically.  If  the  bowels 
have  not  acted  by  the  end  of  the  first  week,  give  an  enema 
and  follow  this  by  a  saline.  Remove  the  drainage-tube  on 
the  third  day.     At  the  end  of  about  three  weeks,  if  a  radical 


DISEASES  AND   INJURIES   OF   THE  ABDOMEN.       653 

cure  has  not  been  attempted,  get  the  patient  up,  first  apply- 
ing a  pad  and  a  spica  of  the  groin.  A  truss  cannot  be  worn 
for  five  or  six  weeks. 

Anatomical  Varieties  of  Haviia. — In  direct  inguinal  hernia 
the  boVvel  passes  out  through  Hesselbach's  triangle  internal 
to  the  deep  epigastric  artery.  It  enters  the  inguinal  canal 
low  down,  and  passes  outside  the  conjoined  tendon  or  forces 
the  conjoined  tendon  before  it  or  splits  through  the  tendon. 
The  neck  of  the  sac  is  internal  to  the  deep  epigastric  artery. 
The  coverings  of  this  hernia  when  it  passes  external  to  the 
conjoined  tendon  are  the  same  as  for  indirect  inguinal  hernia ; 
when  a  direct  hernia  pushes  before  it  the  conjoined  tendon, 
its  coverings  are  skin,  superficial  fascia,  intercolumnar  fascia, 
conjoined  tendon,  transversalis  fascia,  subserous  tissue,  and 
peritoneum.  In  indirect  inguinal  hernia  the  bowel  passes 
through  the  internal  abdominal  ring  external  to  Hesselbach's 
triangle  and  external  to  the  deep  epigastric  artery.  It  passes 
down  the  inguinal  canal  and  emerges  from  the  external 
ring ;  it  may  enter  the  scrotum  or  labium  (scrotal  or  labial 
hernia),  or  it  may  not.  The  neck  of  the  sac  is  external 
to  the  deep  epigastric  artery.  Its  coverings  are — skin, 
superficial  fascia,  intercolumnar  fascia,  cremaster  muscle, 
infundibuliform  fascia,  subserous  tissue,  and  peritoneum. 
Congenital  or  encysted  inguinal  hernia  is  a  hernia  into  an 
unclosed  vaginal  process.  The  bowel  in  congenital  hernia 
has  one  layer  of  peritoneum  in  front  of  it.  The  testicle  is 
posterior.  In  funicular  Jiernia  the  vaginal  process  is  closed 
below  and  open  above,  and  a  hernia  takes  place  into  the  un- 
closed funicular  process.  The  bowel  has  one  layer  of  peri- 
toneum in  front  of  it.  The  testicle  is  posterior.  In  infantile 
hernia  the  vaginal  process  is  occluded  above,  and  not  below, 
and  the  septum  of  occlusion  is  pushed  down  by  the  hernia. 
In  infantile  hernia  the  bowel  has  three  layers  of  peritoneum 
in  front  of  it.     The  testicle  is  in  front.     Always  remember 


654  ^    MANUAL    OF  SURGERY. 

that  congenital  hernia  may  not  appear  for  several  months 
after  birth.  Congenital  hernia  conceals  or  buries  the  testicle  ; 
acquired  hernia  does  not.  In  fcnionil  /icniia  the  bowel  de- 
scends along  the  femoral  canal,  and  the  neck  of  the  sac  is  at 
the  femoral  ring.  A  femoral  rupture  is  always  external  to 
the  pubic  spine;  an  inguinal  rupture  is  always  internal  to 
the  pubic  spine.  Femoral  hernia  is  never  congenital.  Its 
coverings  are — skin,  superficial  fascia,  cribriform  fascia,  crural 
sheath,  septum  crurale,  subserous  tissue,  and  peritoneum. 
Umbilical  hernia  may  be  congenital  (the  ventral  plates  having 
closed  incompletely),  infantile  (the  cicatrix  of  the  umbilicus 
having  stretched),  or  acquired.  Ventral  Jiernia  is  a  protru- 
sion at  any  part  of  the  anterior  abdominal  wall  except  at  the 
umbilicus.  Obturator  hernia  passes  through  the  obturator 
membrane  or  the  obturator  canal,  and  is  felt  below  the  hori- 
zontal ramus  of  the  pubes,  internal  to  the  femoral  vessels. 
Lumbar  hernia  occurs  at  the  edge  of,  or  through,  the  quad- 
ratus  lumborum  muscle.  Sciatic  hernia  passes  through  the 
great  sacro-sciatic  foramen.  In  diaphragmatic  hernia  some 
viscera  of  the  abdomen  pass  through  a  natural  or  an  acci- 
dental opening  into  the  thorax.  Pudendal  Jiernia  protrudes 
into  the  lower  part  of  the  labium.  Perineal  Jiernia  presents 
in  the  perineum,  between  the  rectum  and  the  prostate  gland 
or  between  the  rectum  and  the  vagina.  Hernia  into  tJie  fora- 
men of  Winslozv  is  very  rare. 

XXVII.    DISEASES  AND   INJURIES  OF  THE 
RECTUM  AND  ANUS. 

Hemorrhoids,  or  Piles. — There  are  three  varieties  of 
varicose  tumors  of  the  rectum,  namely:  internal,  which  take 
origin  within  the  external  sphincter;  external,  which  take 
origin  without  the  external  sphincter ;  and  mixed  hemor- 
rhoids, which  are  a  combination  of  the  two. 


DISEASES  AND   INJURIES   OF  RECTUM  AND  ANUS.    65  5 

External  Hemorrhoids. — A  livid,  soft  enlargement  ap- 
pears near  the  edge  of  the  anus,  due  to  rupture  of  a  dis- 
tended vein,  and  accompanied  by  decided  pain  and  other 
evidences  of  inflammation.  These  blood-tumors  may  get 
well  if  let  alone,  or  they  may  suppurate.  External  piles  are 
covered  with  skin,  are  apt  to  be  multiple,  and  cause  no  pain 
except  when  inflamed.  When  the  superfluous  tags  of  skin 
around  the  anus  enlarge,  they  give  rise  to  much  pain  and 
inflammation.  These  cutaneous  outgrowths  are  often  spoken 
of  as  a  form  of  external  piles. 

Symptoms  and  Treatment. — An  inflammatory  enlargement 
is  detected,  which  enlargement  is  tender  and  painful.  Pain 
is  increased  by  defecation.  These  piles  do  not  bleed.  In 
treating  external  hemorrhoids  some  surgeons  merely  use 
remedies  to  combat  the  inflammation.  An  old  plan  of  treat- 
ment is  to  incise  the  blood-tumor,  turn  out  the  clot,  and 
pack  with  a  bit  of  iodoform  gauze.  Matthews  freezes  the 
part  or  injects  cocaine,  catches  up  the  blood-tumor  with  a 
volsellum,  excises  the  tumor  and  the  tabs  of  inflamed 
skin,  dusts  the  part  with  iodoform,  and  dresses  it  with  anti- 
septic gauze.  The  bowels  should  be  tied  up  for  two  days. 
Never  inject  external  piles  with  carbolic  acid :  it  causes 
great  inflammation,  excessive  pain,  and  is  not  free  from  danger. 
If  the  patient  declines  operation,  order  rest,  a  non-stimulating 
diet,  avoidance  of  tobacco  (Matthews),  a  saline  purgative, 
injections  into  the  rectum  of  cold  water  several  times  a  day, 
sponging  of  the  anus  frequently  with  hot  water,  and  the 
application  of  hot  poultices.  As  the  acute  symptoms  begin 
to  disappear  use  lead-water  and  laudanum  ;  when  they  have 
nearly  subsided,  apply  zinc  ointment.  Extract  of  hamamelis 
is  a  valuable  application  to  external  piles. 

Internal  hemorrhoids  are  internal  to  the  external  sphinc- 
ter, just  within  the  anus,  and  they  prolapse  easily.  They 
are    covered    by    mucous    membrane.      Capillary   piles    are 


656  A   MANUAL    OF  SURGERY. 

small,  sessile,  with  a  surface  like  a  mulberry,  and  bleed 
freely.  Children  are,  as  a  rule,  not  very  liable  to  develop 
piles,  but  they  not  infrequently  have  this  capillary  form. 
Venous  piles  are  the  ones  commonly  met  with.  They 
extend  from  just  above  the  anal  margin  of  the  rectum  for 
an  inch  or  more.  They  are  purple  in  color,  soft,  irregular 
in  outline,  and  are  usually  multiple.  They  bleed,  but  not 
so  easily  as  the  capillary  pile,  when  irritated  by  hard  fecal 
masses.  Each  pile  is  composed  of  a  varicose  vein,  some 
little  fibrous  tissue,  and  a  few  arterial  twigs.  Arterial  piles 
are  very  unusual.  They  are  large,  smooth,  pedunculated, 
and  bleed  easily  and  freely.  Each  pile  contains,  besides  a 
distended  vein,  arteries  of  some  size. 

Anything  producing  venous  congestion  in  the  rectum — 
constipation,  diseases  of  the  rectum,  enlargement  of  the 
prostate,  pregnancy,  tumors  of  the  womb,  congestion  of  the 
liver,  cirrhosis  of  the  liver,  certain  diseases  of  the  heart 
and  lungs,  sedentary  occupations,  relaxing  climate,  and  stric- 
ture of  the  urethra — will  cause  hemorrhoids. 

Symptoms  and  Treatment. — If  there  is  no  bleeding  and 
no  protrusion,  the  piles  give  no  trouble.  The  first  symptom 
is  usually  hemorrhage,  and  rectal  examination  by  the  spec- 
ulum will  make  clear  the  condition.  After  a  time,  during 
defecation,  the  piles  protrude ;  they  may  reduce  themselves 
when  the  patient  stands  up,  or  it  may  be  necessary  to  push 
them  in.  Pain  does  not  exist  in  uncomplicated  cases,  and 
pain  during  or  after  protrusion  means  "  abrasion,  fissure,  or 
ulceration"  (Matthews).  Palliative  treatment  will  not  cure, 
but  it  will  give  great  comfort.  Some  people  only  suffer  at 
rare  times  when  the  liver  is  congested,  and  such  subjects  will 
not  submit  to  operation.  Remove,  if  possible,  the  cause  (alco- 
hol, irritating  foods,  want  of  exercise,  etc.)  ;  restrict  the  diet; 
insist  on  regular  exercise ;  give  a  course  of  Carlsbad  salt, 
and  follow  this  by  the  stomach  use  of  bichloride  of  mercury 


DISEASES  AND   EXJUKIES   OE  RECTUM  AND   ANUS.     657 

(gr.  2V  after  each  meal).  Prevent  constipation  by  a  nightly 
dose  of  fluid  extract  of  cascara  sagrada.  After  each  move- 
ment wash  off  the  parts  and  syringe  out  the  rectum  with 
cold  water,  and  dry  with  a  soft  rag.  If  the  hemorrhoids 
prolapse,  after  restoring  them  and  injecting  water,  insert  a 
suppository  containing  gr.  v  of  the  extract  of  hamamelis, 
and  use  another  suppository  at  bed-time.  When  the  piles 
prolapse  and  inflame,  rub  Aliingham's  ointment  on  the  parts 
(sij  each  of  ext.  of  conium  and  ext.  of  hyoscyamus,  5J  of 
ext.  of  belladonna,  and  5J  of  cosmoline).  Matthews  uses 
gr.  xij  of  cocaine,  5j  of  iodoform,  oSS  of  ext.  of  opium,  5J  of 
cosmoline.  If  the  piles  are  protruding  and  reduction  cannot 
be  effected,  put  the  patient  to  bed,  give  a  hypodermatic  injec- 
tion of  morphia,  and  apply  hot  poultices.  If  reduction  can- 
not soon  be  effected,  operate. 

Operative  Treatment. — Give  a  saline  the  morning  before, 
and  an  enema  the  evening  before,  the  operation,  and  wash  out 
the  rectum  well  the  morning  of  the  operation.  In  treating 
by  injection  of  carbolic  acid  the  tum.ors  are  drawn  out  or  the 
patient  strains  them  out,  an  injection  is  given  by  a  hypoder- 
matic syringe  into  the  centre  of  the  pile,  and  as  each  pile 
is  injected  it  is  pushed  into  the  rectum.  The  dose  for  each 
pile  is  10  drops  of  a  solution  containing  3  parts  of  glycerin, 
3  of  water,  and  i  of  pure  carbolic  acid.  The  injection  is 
rarely  curative,  is  very  painful,  and  may  produce  hemorrhage, 
phlebitis,  pyemia,  stricture,  and  even  death  (W.  T.  Bull). 
The  clamp  and  cautery  are  used  in  interno-external  piles. 
The  pile  is  caught  with  forceps  and  drawn  outside.  Smith's 
clamp  is  applied  with  the  ivory  surface  against  the  mucous 
membrane  of  the  bowel,  the  pile  is  cut  off,  and  the  stump 
is  seared  with  the  Pacquelin  cautery  at  a  dull-red  heat. 
Excision  is  preferred  by  Allingham.  He  stretches  the  sphinc- 
ter, holds  it  open  with  a  retractor,  catches  up  the  pile,  cuts 
it  off,  and  twists  the  bleeding  vessels.     Some  prefer  to  pass 

42 


658  ^   MANUAL    OF  SURGEf!Y. 

a  ligature,  cut  off  the  tumor,  and  tie  the  thread  (Fig.  166). 
Whitehead's  operation  is  suited  to  severe  cases,  and  only 
a  surgeon  who  can  master  violent  hemorrhage  should 
venture  to  perform  it.  The  entire  pile-bearing  area  of 
mucous  membrane  is  dissected  out,  and  the  cut  margin 
of  mucous  membrane  is  pulled  down  and 
stitched  to  the  surface.  The  sphincter  must 
be  dilated  as  a  preliminary. 

TJie  ligature  is  the  easiest  and  most  gen- 
erally useful  method.  In  this  operation  stretch 
the  sphincter  and  treat  each  haemorrhoid  sep- 
arately. Catch  a  pile  with  a  pair  of  forceps 
or  a  volsellum,  pull  it  down,  and  cut  a  gutter 
Fig.  i66.-Extir-  throug^h  the  skin-margin  ;  tie  the  small  piles 

pation     of    Hemor-  ^  r  i         i  -i       \ 

rhoids(Esmarchand  without  transfixing  (transfix  the  large  piles) ; 
Kowaizig).  ^j^  ^^,|^l^  gjlj^  (coarse  silk  for  the   large  piles, 

finer  silk  for  the  small  piles) ;  cut  off  the  tumor,  and  cut 
the  ligatures  short.  Treat  the  other  piles  in  the  same 
manner.  Irrigate  with  corrosive-sublimate  solution,  dust 
with  iodoform,  pack  a  piece  of  iodoform  gauze  into  the 
rectum,  and  apply  a  gauze  pad  and  a  T-bandage.  Give  some 
morphia  to  lock  up  the  bowels,  and  keep  the  patient  on  a 
light  diet  for  three  days,  at  the  end  of  which  time  a  saline 
may  be  given.  Just  before  the  bowels  act  remove  the 
dressings  and  give  an  enema  of  warm  water.  After  the 
movement  wash  out  the  rectum  with  i  :  5000  corrosive- 
sublimate  solution  and  apply  a  gauze  pad  over  the  anus. 
Irrigate  daily  until  healing  is  complete.  After  the  tenth 
day  examine  with  a  speculum  to  see  that  the  ligatures  have 
come  away ;  if  any  are  found  in  place,  remove  them. 

Prolapse  of  Rectum. — If  the  mucous  membrane  alone  is 
prolapsed,  the  condition  is  called  "  prolapsus  ani ;"  if  the 
entire  thickness  of  the  rectal  w^all  is  prolapsed,  it  is  called 
"  prolapsus  recti."     Prolapse,  which   is   apt  to   occur  from 


DISEASES  AND  INJURIES   OE  RECTUM  AND  ANUS.     659 

excessive  straining  at  stool,  is  commonest  in  feeble,  ill- 
nourished  children.  Piles  and  worms  may  be  complicated 
with  prolapse.  Straining  from  phimosis,  stone  in  the  blad- 
der, or  stricture  may  be  causative.  Prolapse  may  be  either 
large  or  small,  but  it  tends  to  recur  again  and  again,  and 
eventually  the  mucous  membrane  inflames,  ulcerates,  or 
sloughs.     Strangulation  of  the  prolapsed  part  may  occur. 

Treatment. — In  palliative  treatment  the  patient  must  not 
strain  at  stool ;  if  prolapse  occurs,  the  parts  are  bathed  in 
cold  water  and  restored.  Constipation  must  be  prevented 
(enemata  of  water  or  glycerin  may  be  used).  If  a  prolapse 
is  caught  firmly,  place  the  patient  upon  his  knees  and  chest, 
wash  the  mass  with  cold  water,  grease  it  with  cosmoline, 
insert  a  finger  into  the  rectum,  and  apply  taxis  around  the 
finger  (Matthews).  If  this  fails,  cover  a  finger  with  a  hand- 
kerchief and  insert  the  wrapped  digit  into  the  rectum  ;  if  this 
prove  futile,  invert  the  patient.  Severe  cases  require  ether. 
After  reduction  apply  a  compress,  direct  it  to  be  worn 
except  when  at  stool,  and  before  each  act  of  defecation  give 
an  injection  of  cold  water  containing  an  astringent  (tannin 
or  fluid  hydrastis).  Some  bad  cases  require  excision  of  the 
mucous  membrane,  the  divided  edge  of  this  membrane  being 
stitched  to  the  skin. 

Ulcer  of  the  Rectum. — Simple  ulcer  is  due  to  abrasion 
with  fecal  masses,  and  is  apt  to  be  single.  Its  base  and 
edges  are  neither  prominent  nor  hard.  Syphilitic  ulcer  is  a 
tertiary  lesion  commonest  in  women.  There  are  numerous 
small  ulcers,  but  little  indurated,  with  sharp-cut  edges  which 
are  not  undermined.  These  ulcers  fuse  together  and  consti- 
tute one  large  irregular  ulcer ;  fibrous  tissue  forms  in  the 
wall  of  the  bowel,  induration  becomes  noticeable,  and  stric- 
ture follows.  There  is  profuse  discharge,  and  fistulse  are  apt 
to  form.  In  syphilis  there  may  be  a  breaking  down  of  a 
huge  gummy  mass.    Tubercular  ulceration  presents  a  conical 


66o  A   MANUAL    OF  SUJ^GERY. 

ulcer  with  overhanging  edges  and  a  pale-red  base.  There 
is  some  mucous  discharge,  some  tenesmus,  and  a  little  pain. 
Dysentery,  catarrh,  neoplasms,  and  foreign  bodies  produce 
ulceration.  The  syniptonis  are  constipation,  burning  pain  on 
defecation,  straining  at  stool,  and  blood  and  mucus  in  the 
stools.  The  diagnosis  is  made  by  the  finger  and  the  specu- 
lum. 

Treatment. — In  simple  ulcer,  empty  the  bowel  with  a 
saline,  wash  it  out  with  hot  water,  introduce  a  speculum, 
touch  the  ulcer  with  pure  carbolic  acid  or  silver  nitrate 
(gr.  xl  to  5J),  place  the  patient  in  bed,  restrict  to  a  liquid 
diet,  and  every  day  inject  iodoform  and  olive  oil  or  insufflate 
iodoform.  In  tubercular  ulcer,  improve  the  general  health, 
send  the  patient  to  a  genial  climate  or  at  least  into  the  sun- 
light and  fresh  air,  prevent  constipation,  give  cod-liver  oil,  and 
wash  out  the  rectum  every  day  with  hot  water  and  insufflate 
iodoform.  Touch  the  ulcer  once  a  week  with  silver  nitrate 
(gr.  X  to  5j).  In  syphilitic  ulcer,  give  antisyphilitic  treatment 
and  treat  the  ulcer  locally  as  is  done  in  tubercular  ulcer. 
Dysenteric  ulcer  requires  injections  of  hot  water  and  the 
touching  of  the  ulcer  with  pure  carbolic  acid  and  insuffla- 
tions of  iodoform. 

Stricture  of  the  rectum  may  arise  from  syphilitic  tissue, 
from  ordinary  inflammatory  tissue,  from  cicatrices  of  opera- 
tions, from  sloughing,  from  tubercular  or  dysenteric  ulcera- 
tion, and  from  cancer.  The  usual  seat  of  simple  stricture  is 
from  one  inch  to  one  and  a  half  inches  above  the  anus. 
The  deposit  may  be  limited  to  the  submucous  coat  or  all 
the  coats  may  be  involved. 

Symptoms  and  Treatment. — The  symptoms  of  rectal  stricture 
are  constipation,  pain  on  defecation,  straining  at  stool,  blood 
and  mucus  in  the  stools,  an  open  anus,  and  stools  flattened 
out  into  ribbons.  The  stricture  is  found  by  the  finger  or  by 
the  bougie.     Complete  obstruction  may  come  on,  and  dis- 


DISEASES  AND   INJURIES   OF  RECTUM  AND  ANUS.     66 1 

tended  abdomen  with  colic  is  very  usual.  The  trcatiuoit  is 
rest,  non-stimulating  diet,  warm-water  injections,  mild  laxa- 
tives, and  hot  hip-baths.  Cocaine  suppositories  may  be 
needed.  Any  existing  disease  is  treated.  Bougies  are 
passed  every  other  day.  Use  a  soft-rubber  bougie,  warmed 
and  oiled,  and  introduce  it  gently.  If  this  method  of  gradual 
dilatation  is  employed  the  bougie  must  be  used  always.  For 
fibrous  strictures  forcible  dilation  (divulsion)  by  a  special 
instrument  is  employed  or  incision  is  practised.  Incision 
(proctotomy)  may  be  either  external  or  internal.  In  in- 
ternal proctotomy  one  or  more  incisions  are  made  through 
the  stricture  down  to  health}-  tissue,  the  first  cut  being  in  the 
middle  line  posteriorly.  External  proctotomy,  which  divides 
the  sphincters,  is  apt  to  leave  incontinence  as  a  legacy. 
Electrolysis  finds  some  advocates,  but  on  what  grounds  it  is 
difficult  to  see.  In  some  cases  the  rectum  should  be  re- 
moved.    Complete  obstruction  calls  for  inguinal  colostomy. 

Cancer  of  the  rectum  may  be  epithelioma,  but  it  is  often 
scirrhus.  It  not  unusually  occurs  before  the  thirty-fifth  year. 
The  retroperitoneal  and  inguinal  glands  are  involved  late  or 
not  at  all.  Extensive  ulceration  occurs.  A  hard  ring  is  apt 
to  encircle  the  rectum. 

Symptoms  afid  Treatment. — The  symptoms  of  rectal  cancer 
are  like  those  of  simple  ulcer  except  that  the  pain  is  greater, 
the  hemorrhage  more  severe,  and  constipation  is  apt  to  alter- 
nate with  diarrhoea.  The  finger  and  the  speculum  make  the 
diagnosis.  Palliative  treatment  is  as  follows  :  Every  day  in- 
troduce a  tube  through  the  stricture,  wash  out  the  rectum 
with  warm  water,  and  after  washing  inject  emulsion  of 
iodoform  (grs.  x  J:o  5J  of  sweet  oil).  Injections  of  chloride 
of  zinc  (gr.  j  to  5J  of  water)  lessen  the  foulness  of  the  dis- 
charge. In  operative  treatment  internal  proctotomy  does 
some  good.  Excision  of  the  rectum  from  below  (Cripp's 
operation)  is  practised  if  not  more  than  three  inches  require 


662  A   MANUAL    OF  SURGERY. 

removal,  if  the  peritoneum  is  not  invaded,  and  if  the  adjacent 
organs  are  free  from  disease.  The  peritoneum  must  not  be 
opened  in  Cripp's  operation.  Excision  of  the  rectum  after 
excising  a  portion  of  the  sacrum  (Kraske's  operation)  is  an 
operation  which  permits  removal  of  the  entire  tube,  and 
even  of  adjacent  parts.  If  the  peritoneum  is  opened,  it  is 
closed  with  sutures.  It  is  well  to  precede  a  Kraske  opera- 
tion several  weeks  by  an  inguinal  colostomy,  which  per- 
mits of  cleansing  the  lower  bowel  from  feces  and  allows  the 
surgeon  to  operate  with  a  fair  chance  of  escaping  infection. 
In  obstruction  from  cancer,  or  in  cases  that  do  not  permit 
of  removal,  inguinal  colostomy  is  performed.  It  intercepts 
the  feces  from  the  cancerous  region,  allays  pain,  and  pro- 
longs  life. 

Foreign  bodies  in  the  rectura,  if  small,  are  extracted  with 
forceps  and  the  fingers  ;  if  large,  ether  must  first  be  given  and 
the  sphincter  must  be  dilated. 

"Wounds  of  the  rectum  require  free  drainage,  antiseptic 
irrigation,  and  antiseptic  dressing. 

Ischio-rectal  abscesses  are  situated  in  the  ischio-rectal 
fossa.  They  travel  in  the  line  of  least  resistance,  which  is 
upward,  and  more  often  burst  into  the  bowel  than  externally. 
They  are  caused  by  cold,  by  external  traumatisms,  or  by 
perforations  of  the  rectum  by  hard  fecal  masses.  They 
may  be  tubercular.  The  symptoms  are  the  same  as  those 
of  abscess  anywhere,  the  swelling,  however,  being  brawny 
and  fluctuation  being  hard  to  detect.  The  treatment  is 
instant  incision,  irrigation,  and  packing  wi.th  iodoform  gauze 
or  the  insertion  of  a  drainage-tube. 

Fistula  in  ano  is  the  track  of  an  unheaJed  abscess.  An 
abscess  in  the  anal  region  is  apt  to  refuse  to  heal  because  of 
the  constant  movement  of  the  parts  (respiration,  coughing, 
passage  of  wind,  defecation).  The  passage  of  feces  will 
keep   a   fistula   open.     If  a  tubercular   ulcer   perforates,   a 


DISEASES  AXD   EXJURIES   OF  RECTUM  AXD  AXUS.     663 

tubercular  sinus  forms.  Fistula  is  often  associated  with 
phthisis  pulmonalis,  and  is  not  unusually  linked  with  piles, 
cancer,  or  stricture.  , 

There  are  three  varieties  of  fistula — the  blind  external 
(Fig.  167,  a),  the  blind  internal  (Fig.  167,  b),  and  the  com- 
plete (Fig.  167,  c).  The  cxtcnial  opening  is  usually  near  the 
anus,  but  may  be  far  away,  and  there  may  be  only  one  path- 
way or  there  may  be  several  sinuses.  In  a  healthy  individual 
the  external  orifice  is  small  and  a  mass  of  granulations  sprout 
from  it.  In  tuberculous  fistula  the  external  orifice  is  large 
and  irregular,  with  thin  and   undermined  edges,  shows  no 


Fig.  167. — Fistula  in  Ano  :  a,  blind  external ;  b,  blind  internal ;  c,  complete  (Esmarch 
and  Kowalzig). 

granulations,  extrudes  small  quantities  of  sanious  pus,  and 
the  skin  about  it  is  purple  and  congested  (Bowlby).  In  a 
fistula  following  an  anal  abscess  the  i/itenial  opening  is  just 
above  the  anus,  between  the  two  sphincters.  In  fistula  fol- 
lowing an  ischio-rectal  abscess  the  internal  opening  is  above 
the  internal  sphincter.  In  an  old  fistula  the  track  becomes 
fibrous  and  cannot  collapse.  The  symptoms  of  fistula  are 
passage  of  feces  and  wind  through  the  opening  and  of  a  dis- 
charge which  stains  the  clothing.  A  probe  can  be  carried 
from  the  external  opening  into  the  bowel.  After  a  time  in- 
continence of  feces  is  apt  to  come  on,  repeated  attacks  of 
inflammation  thickening  the  rectum  and  destroying  its  sensi- 


664 


A   MANUAL    OF  SURGERY. 


bility.  From  time  to  time  the  opening  will  block,  and  new 
abscesses  may  then  form.  In  examining  a  fistula,  use  Brodie's 
probe,  as  its  flat  handk  enables  one  to  locate  the  direction  a 
bent  probe  has  taken. 

Treatment. — In  treating  a  fistula  prepare  the  parts  antisep- 
tically,  as  antiseptic  work,  though  it  will  not  prevent  pus,  will 
limit  suppuration.  Pass  a  grooved  director  through  the 
sinus,  bring  its  point  out  externally,  and  lift  up  the  tissues 
between  the  sinus  and  the  surface.  Incise  the  tissues  (Fig. 
1 68).  Push  the  finger  to  the  depth  of  the  wound,  to  deter- 
mine that  the  sinus  does  not  ascend  above 
the  internal  opening.  Slit  up  the  sinuses 
and  scrape  them.  Curette  the  sinus,  and 
if  it  is  very  fibrous  clip  it  away  with  scis- 
sors and  forceps.  Cut  away  diseased  skin  ; 
irrigate  with  corrosive-sublimate  solution 
(i  :  looo) ;  pack  with  iodoform  gauze  ;  and 
dress  with  gauze  and  a  T-bandage.  In 
forty-eight  hours  remove  the  dressings, 
irrigate  with  peroxide  of  hydrogen  and 
then  with  corrosive  sublimate  (i  :  5000), 
dust  in  iodoform,  insert  lightly  to  the  depths  of  the  wound 
a  piece  of  iodoform  gauze,  and  reapply  the  dressings.  Dress 
the  wound  thus  every  day  until  healing  is  almost  complete. 
It  is  unnecessary  to  confine  the  bowels  beyond  forty-eight 
hours,  at  which  period,  if  they  have  not  moved,  an  enema  is 
given.  If  the  dressing  be  stained  with  feces,  re-dress  at 
once.  Get  the  patient  out  of  bed  as  soon  as  possible.  Should 
an  operation  be  undertaken  if  phthisis  exists  ?  Many  of  the 
old  masters  said  no.  Matthews  sums  up  the  modern  view : 
In  incipient  phthisis,  operate ;  in  rapidly  progressive  fistula, 
operate  whether  cough  exists  or  not ;  if  much  cough  exists, 
do  not  operate  unless  the  fistula  is  rapidly  progressive ;  in 
the  last  stages  of  phthisis,  do  not  operate. 


liig  168 — Operation 
for  Fistula  in  Ano  (Es- 
march  and  Kowalzig). 


DISEASES  AND  INJURIES   OF  RECTUM  AND  ANUS.    665 

Pruritus  of  the  anus  is  a  symptom,  and  not  a  disease.  It 
may  be  due  to  piles,  fissure,  seat-worms,  eczema,  nerve-dis- 
turbance, kidney-disease,  jaundice,  constipation,  opium-habit, 
torpid  Hver,  dyspepsia,  alcohol,  tea,  vesical  calculus,  smoking, 
urethral  stricture,  uterine  disease,  ovarian  trouble,  and  men- 
tal disorder.    The  itching,  which  is  fearful,  is  worse  at  night. 

Treatment. — Remove  the  cause.  Further,  before  going  to 
bed  wash  the  parts  with  very  hot  water,  dry  them,  and  apply 
at  frequent  intervals  a  mixture  containing  3j  of  campho- 
phenique  and  5J  of  water  (Matthews).  Matthews  commends 
the  following  mixture :  Chloral,  3J ;  gum-camphor,  3ss ; 
glycerin  and  water,  each  5J.^  In  this  disease  a  **  scarf- 
skin  "  forms,  which  must  be  made  to  peel  off  by  iodine,  pure 
carbolic  acid,  corrosive  sublimate  (grs.  iv  to  5J  of  cosmoline), 
calomel  (.5ij  to  ^j  of  cosmoline),  or  campho-phenique. 

Fissure  of  the  anus  is  a  crack  at  the  anal  orifice  pro- 
ducing spasm  of  the  sphincter.  The  pain  is  due  to  twigs 
of  nerves  upon  the  floor  of  the  crack.  Fissure  is  caused  by 
constipation  or  traumatism.  The  symptom  is  violent  burning 
pain,  sometimes  beginning  during  defecation,  but  usually  at 
the  end  of  the  act,  and  lasting  for  some  time.  Constipation 
exists,  and  often  pruritus.  Examination  discloses  a  fissure, 
usually  at  the  posterior  margin,  running  up  the  bowel  one- 
quarter  to  one-half  an  inch.     Piles  often  exist  with  fissure. 

Treatment. — In  palliative  treatment  prevent  constipation, 
wash  out  the  rectum  with  cold  water,  and  apply  an  ointment 
made  by  evaporating  sij  of  the  juice  of  conium  to  ^ij  and 
adding  it  to  Ij  of  lanolin  and  grs.  xij  of  persulphate  of  iron. 
In  operative  treatment  stretch  the  sphincter,  incise  the  floor 
of  the  fissure,  and  scrape  it  with  a  curette. 

^  Diseases  of  the  Rectum. 


666  A   MANUAL    OF  SURGERY. 

XXVIII.    ANyESTHESIA  AND   ANESTHETICS. 

Aucesihesia  is  a  condition  of  insensibility  or  loss  of  feeling 
artificially  produced.  An  ancesthdic  is  an  agent  which  pro- 
duces insensibility  or  loss  of  feeling.  Anaesthetics  are 
divided  into — (i)  General  ancesthetics,  as  amylene,  chloro- 
form, ethylene  chloride,  ether,  bromide  of  ethyl,  nitrous  oxide, 
and  bichloride  of  methylene ;  (2)  Local  ancBsthctics,  as  alco- 
hol, bisulphide  of  carbon,  chloride  of  ethyl,  carbolic  acid, 
ether  spray,  cocaine,  ice  and  salt,  and  rhigolene  spray. 

General  anaesthesia  may  be  required  to  prevent  the  pain 
of  labor  and  of  surgical  procedures;  to  produce  muscular 
relaxation  in  herniae,  dislocations,  and  fractures ;  and  to  aid 
in  diagnosticating  abdominal  tumors,  joint  diseases,  and 
malingering. 

Heart  disease  is  not  a  positive  contraindication  to  surgical 
anaesthesia.  It  is  quite  true  that  anaesthetics  are  dangerous 
in  people  with  fatty  hearts,  but  shock  is  equally  dangerous, 
and  the  surgeon  stands  between  the  Scylla  of  anaesthesia 
and  the  Charybdis  of  shock.  Whenever  possible,  prepare 
a  patient  for  anaesthesia.  Always  examine  the  urine  if  the 
nature  of  the  case  allows  time.  If  albumin  exists,  operation 
is  not  contraindicated ;  but  the  peril  of  anaesthesia  is  greater, 
and  certain  dangers  are  to  be  watched  for  and  guarded 
against.  If  much  albumin  is  present,  postpone  operation 
except  in  emergency  cases.  Give  a  purgative  the  night 
before.  In  the  morning,  allow  no  breakfast  if  the  operation 
is  early,  but  if  the  patient  is  very  weak  order  a  little  brandy 
and  beef-tea.  If  the  operation  is  to  be  about  noon,  give  a 
breakfast  of  some  beaf-tea  and  toast  or  a  little  consomme ; 
never  give  any  food  within  three  hours  of  the  operation,  but 
brandy  is  admissible  if  it  is  required.  If  the  stomach  is  not 
empty  at  the  time  of  operation,  vomiting  is  inevitable  and 
portions  of  food   may  enter  the  windpipe ;  if  the   stomach 


ANAESTHESIA   AND  ANAESTHETICS.  667 

contains  no  food,  vomiting  is  less  likely  to  happen,  and  even 
if  the  vomited  matter  enters  the  windpipe  it  will  do  little 
harm,  as  it  consists  chiefly  of  liquid  mucus.  Vomiting  is 
dangerous  also  because  of  the  great  cardiac  weakness  which 
precedes  and  follows  it.  Before  giving  the  anaesthetic  see 
that  artificial  teeth  are  removed  and  that  the  patient  does 
not  have  a  piece  of  candy  or  a  chew  of  tobacco  in  the 
mouth.  Always  have  a  third  party  present  as  a  witness, 
because  in  the  anaesthetic  sleep  vivid  dreams  often  occur, 
and  erotic  dreams  in  women  may  lead  to  damaging  accusa- 
tions against  the  surgeon.  Place  the  patient  recumbent,  and 
see  that  the  clothing  is  loose,  particularly  that  there  is  no 
constriction  about  the  neck  and  abdomen.  Do  not  have  the 
head  high  unless  this  position  is  demanded  by  the  exigencies 
of  the  operation.  The  anaesthetizer  must  have  a  mouth-gag, 
a  pair  of  tongue-forceps,  a  hypodermic  needle  in  zuorking 
order,  and  solutions  of  strychnia,  atropia,  digitalis,  and 
brandy.  It  is  always  well  to  have  an  electric  battery  at 
hand.  Accidents,  it  is  true,  are  rare,  but  they  may  happen 
at  any  time,  and  hence  the  surgeon  should  always  be  pre- 
pared for  them.  Any  danger  which  arises  must  be  met 
with  promptness  and  decision,  or  action  will  be  of  no  avail. 
Many  surgeons  give  a  hypodermatic  injection  of  morphia 
a  short  time  before  operation,  to  steady  the  heart,  prevent 
vomiting,  and  aid  the  bringing  about  of  insensibility  with 
very  little  of  the  anaesthetic. 

The  two  favorite  anaesthetics  are  ether  and  chloroform. 
Chloroform  is  more  dangerous  than  ether  in  general  cases, 
though  it  is  more  agreeable,  less  irritant  to  the  lungs  and 
kidneys,  and  quicker  in  its  action.  Recovery  from  chloro- 
form is  quicker  and  quieter  than  that  from  ether,  but  chloro- 
form vomiting  lasts  longer  than  ether  vomiting.  Chloroform 
may  induce  sudden  and  even  fatal  syncope.  Dr.  Hare's 
experiments    on    animals    show   that   chloroform    may   kill 


668  A   MANUAL    OF  SURGERY. 

through  the  respiration ;  but  certain  it  is  that  cHnically  the 
danger  of  chloroform  is  paralysis  of  the  heart,  and  this 
condition  may  come  on  so  rapidly  that  death  can  occur  almost 
before  an  attempt  can  be  made  to  save  life.  If  ether  kills, 
it  does  so  through  the  respiration,  and  not  the  heart,  and 
there  is  usually  time  to  undertake  means  of  resuscitation, 
which  means  arc  apt  to  be  successful.  Chloroform  is  to  be 
preferred  to  ether  in  the  following  cases :  for  children  under 
ten  years  of  age,  in  whom  ether  causes  a  great  outflow  of 
bronchial  mucus  which  may  asphyxiate;  for  people  over 
sixty,  at  which  age  most  persons  have  some  bronchitis, 
and  ether  fills  them  up  with  mucus  (ether  irritates  kidneys, 
which  at  the  latter  age  are  apt  to  be  weak  or  diseased) ; 
for  labor  cases,  when  moderate  anaesthesia  only  is  required  ; 
for  operations  on  the  mouth  and  nose  (unless  the  Trendelen- 
burg chair  is  used,  when  ether  can  be  employed).  In  cleft 
palate  chloroform  should  always  be  used  to  limit  cough  and 
to  minimize  salivary  flow.  In  ligation  of  a  large  artery  which 
is  overlaid  by  a  vein  ether  must  not  be  used,  as  it  greatly 
enlarges  the  veins.  Chloroform  is  preferred  for  patients  with 
difficult  respiration  from  any  cause  ;  for  patients  with  kidney 
disease ;  for  patients  with  diabetes ;  and  in  ovariotomy,  be- 
cause of  a  belief  by  many  surgeons  that  ether  causes  oozing 
of  blood.     Ether  is  safer  in  patients  with  heart  disease. 

Administration  of  Chloroform. — In  administering  chloro- 
form, have  at  hand  a  mouth-gag,  tongue-forceps,  a  clean 
towel,  a  hypodermatic  syringe,  solutions  of  strychnine, 
atropine,  and  brandy,  and,  if  possible,  an  electric  battery. 
Use  only  pure  chloroform  (Squibb's).  The  patient  must  be 
recumbent.  No  special  inhaler  is  required,  but  the  drug 
can  be  given  upon  a  thin  towel,  a  napkin,  or  a  piece  of  lint. 
The  chloroform  vapor  must  be  well  mixed  with  air.  The 
chloroform  is  sprinkled  on  the  fabric  with  a  drop-bottle. 
Put  the  napkin  well  above  the   mouth,  add   five  drops   of 


ANMSTHESIA   AND   AN.-ESTHETICS. 


669 


chloroform,  and  tell  the  patient  to  take  deep  and  regular 
breaths.  Add  a  few  more  drops  of  chloroform,  and  when 
the  patient  grows  so  accustomed  to  it  as  not  to  choke,  turn 
the  wet  part  of  the  fabric  toward  the  face  and  place  it  near 
the  mouth  ;  do  not  touch  the  mouth  with  the  wet  lint,  because 
it  will  blister.  It  is  a  good  plan  to  smear  the  lips  with  cos- 
moline  to  prevent  blistering.  If  the  drug  is  given  gradually, 
struggling  is  not  usually  violent  or  prolonged.  Never  pour 
on  a  large  amount  at  one  time.  During  the  stage  of  excite- 
ment do  not  suspend  the  administration  of  chloroform  unless 
respiration  becomes  difficult,  in  which  case  suspend  it  until 
the  patient  gets  one  or  two  respira- 
tions. Chloroform  vapor  is  not  in- 
flammable, hence  it  is  safer  than 
ether  when  a  hot  iron  is  to  be  used 
about  the  face  and  when  there  is  a 
lighted  lamp  or  a  stove  in  a  small 
room. 

Administration  of  Ether. — Ether 
is  given  by  means  of  an  Allis  in- 
haler (Fig.  169).  Have  at  hand  the 
same  instruments  as  for  chloroform. 
Place  the  dry  appliance  over  the 
mouth  and  nose,  let  the  patient  take 
several  breaths  to  gain  confidence,  pour  a  few  drops  of  ether 
into  the  cone,  let  the  patient  take  several  more  breaths,  and 
so  on,  gradually  increasing  the  amount  of  ether.  Never  sud- 
denly add  a  large  amount  of  the  anaesthetic :  it  causes 
coughing  and  often  vomiting.  When  the  patient  becomes 
thoroughly  anaesthetized,  diminish  the  amount  of  ether; 
when  bleeding  is  profuse,  do  the  same.  If  a  hot  iron  is 
used  about  the  face,  take  away  the  cone  and  fan  away  the 
ether  before  bringing  the  iron  near.  Have  any  light  set 
high  up,  as  ether  vapor  is  heavier  than  air,  and  no  explosion 


Fig.  169. — Allis  Ether-inhaler. 


670  A   MANUAL    OF  SURGERY. 

is  possible  until  it  reaches  the  level  of  the  flame.  If  the 
vapor  takes  fire,  cover  the  patient's  mouth  and  nose  with 
a  towel. 

Anaesthetic  State  from  Ether  or  Chloroform. — The  in- 
halation of  an  anaesthetic  produces  irritation  of  the  fauces, 
some  cough,  a  profuse  secretion  of  mucus,  acts  of  swallow- 
ing;, dilatation  of  the  pupil,  flushed  face,  and  sometimes 
struggling  (especially  in  children  and  in  drunkards).  The 
cough  soon  ceases,  the  respirations  become  rapid  and  often 
convulsive,  the  pulse  becomes  frequent,  and  the  patient 
passes  into  a  condition  of  active  intoxication  with  preserva- 
tion of  sight  and  touch,  loss  of  hearing  and  smell,  diminu- 
tion of  pain  and  sensibility,  and  often  with  illusions  or  hal- 
lucinations. From  this  state  many  subjects  (strong  men  and 
drunkards)  pass  into  a  stage  of  rigidity  in  which  the  muscles 
become  rigidly  fixed,  the  breathing  impeded,  the  respirations 
stertorous,  and  the  face  bluish  and  congested.  Too  rapid 
forcing  of  the  anaesthetic  tends  to  cause  rigidity,  and  a 
skilled  anaesthetizer  endeavors  to  avoid  its  production, 
because  it  is  dangerous.  The  next  stage  is  one  of  insensi- 
bility :  the  pupils  are  contracted,  but  may  react  slightly  to 
light;  the  conjunctival  reflex  is  gone;  the  lids  are  closed; 
if  the  arm  is  lifted  and  allowed  to  fall,  it  drops  as  a  dead 
weight ;  the  skin  is  cool  and  moist,  and  often  wet  with 
sweat;  the  respirations  are  easy  and  shallow;  the  pulse 
is  slow ;  and  there  is  complete  unconsciousness  to  pain. 
If  anaesthesia  is  deep,  the  contracted  pupils  will  not  react  to 
light ;  if  anaesthesia  is  profound,  the  pupils  dilate,  but  will 
not  react  to  light. 

Always  bear  in  mind  that  a  dilated  pupil  reacting  to  light 
and  associated  with  preserved  conjunctival  reflex  means  that 
anaesthesia  is  not  complete  ;  that  a  contracted  pupil  reacting 
to  light  and  without  conjunctival  reflex  means  moderate 
anaesthesia;    that  a  contracted  pupil  not  reacting  to   light 


ANAESTHESIA   AND  AN-ESTHETICS.  67  I 

and  without  conjunctival  reflex  means  deep  anaesthesia ; 
that  a  dilated  pupil  not  reacting  to  light  and  associated  with 
lost  conjunctival  reflex  means  dangerously  profound  anaes- 
thesia ;  that  weak  pulse  and  pallor  may  be  due  to  nausea, 
but  always  require  instant  attention ;  that  vomiting  may  be 
due  to  forcing  strong  vapor  upon  the  patient,  but  that  it 
may  be  due  to  his  partially  emerging  from  a  state  of  insen- 
sibility. 

Watch  the  pulse  carefully  to  see  if  it  becomes  very  weak, 
irregular,  abnormally  slow,  or  abnormally  fast.  Syncope 
may  be  due  to  nausea,  shock,  hemorrhage,  or  the  giving  of 
too  much  of  the  drug.  Watch  the  respiration,  and  do  not 
forget  that  the  chest-walls  and  belly  may  move  when  no  air 
is  entering  the  lung ;  hence  always  listc?i  to  the  breathing. 
Obstruction  of  the  air-passages  may  be  due  to  some  foreign 
matter,  as  blood  or  vomit,  lodging  in  the  brachial  tubes, 
windpipe,  larynx,  or  pharynx ;  to  falling  back  of  the  tongue 
(swallowing  of  the  tongue) ;  to  closure  of  the  epiglottis ;  or 
to  the  glottis  being  pushed  against  the  pharyngeal  wall  by 
bending  forward  of  the  head.  Some  patients  with  occluded 
nostrils  may  fail  to  get  enough  air  because  of  closure  of  the 
lips.  A  patient  may  appear  to  forget  to  breathe.  Shock  is 
manifested  by  deadly  pallor,  weak  and  irregular  pulse,  slow 
respiration,  cold  extremities,  and  a  drenching  sweat. 

Treatment  of  Complications. — In  rare  cases  oedema  of 
the  lungs  occurs.  This  condition  is  treated  by  instant  vene- 
section, the  inhalation  of  nitrite  of  amyl,  and  the  adminis- 
tration of  stimulants  and  nitro-glycerin.  Vomiting  due  to 
too  much  anaesthetic  is  corrected  by  giving  a  few  breaths 
of  air ;  vomiting  due  to  incomplete  anaesthesia  is  amended 
by  giving  more  of  the  vapor.  When  the  patient  vomits, 
hang  the  head  over  the  edge  of  the  bed,  separate  the 
jaws  with  the  gag,  and  wipe  out  the  vomited  matter, 
mucus,  and    saliva.     Shock   is   treated  by   diminishing   the 


672  A    MANUAL    OF  SURGERY. 

amount  of  the  anaesthetic  given,  by  the  hypodermatic  in- 
jection of  brandy,  strychnine,  or  atropine  (the  last-named 
drug  is  very  useful  when  there  is  a  profuse  sweat),  by  sur- 
rounding the  patient  with  hot  bottles,  or  by  wrapping  him 
in  hot  blankets  and  lowering  the  head  of  the  bed.  A 
tendency  to  syncope  requires  lowering  of  the  head  of  the 
bed,  suspension  of  the  anaesthetic,  and  hypodermatic  injection 
of  strychnine.  In  extreme  syncope,  which  is  most  apt  to 
occur  from  chloroform,  suspend  the  anaesthetic,  open  the 
mouth  with  the  gag,  draw  the  tongue  forward,  make  slow 
artificial  respiration,  not  waiting  for  breathing  to  cease  (which 
it  tends  rapidly  to  do),  and  lower  the  head  of  the  bed.  If  the 
patient  does  not  at  once  improve,  invert  him  completely, 
holding  him  by  the  legs  and  continuing  artificial  respira- 
tion by  compressing  the  sternum  (Nelaton).  By  continuing 
artificial  respiration  the  blood  is  urged  on  through  the  heart. 
Give  hypodermatic  injections  of  ether,  brandy,  strychnine, 
or  even  of  ammonia.  Put  mustard  over  the  heart  and 
spine.  Employ  faradism  to  the  phrenic  nerve  (one  pole  to 
the  epigastric  region,  the  other  to  the  right  side  of  the  root 
of  the  neck).  Let  fresh  air  into  the  room,  put  hot-water 
bottles  around  the  legs,  apply  friction  to  the  extremities, 
wrap  the  patient  in  hot  blankets,  give  an  enema  of  brandy, 
and  hold  ammonia  or  nitrite  of  amyl  to  the  nose. 

"  Forgetting  to  breathe  "  is  met  by  removing  the  inhaler 
and  waiting  a  moment ;  a  breath  will  usually  be  taken  now, 
but  if  it  is  not  taken  open  the  mouth  and  pull  forward  the 
tongue ;  this  causes  a  reflex  inspiration.  Obstruction  to 
breathing  from  bending  forward  of  the  head  may  be  amended 
by  changing  the  position  of  the  head  or  by  pulling  forward 
the  tongue.  Cyanosis,  if  slight,  is  met  by  continuing  the 
anaesthetic  and  by  carrying  the  patient  quickly  into  the  stage 
of  relaxation  ;  but  if  the  condition  grows  worse  suspend  the 
drug,  dash  cold  water  in  the  face,  force  open  the  jaws,  pull 


ANESTHESIA   AND  ANESTHETICS.  673 

forward  the  tongue,  and  make  artificial  respiration  until  a 
breath  is  taken.  "  Swallowing  the  tongue  "  is  corrected  by 
pulling  the  tongue  forward.  If  it  tends  to  recur,  lay  the 
head  upon  its  side  or  keep  the  tongue  anchored  with  forceps. 
Closure  of  the  epiglottis  is  corrected  by  pulling  the  patient's 
head  beyond  the  end  of  the  table  and  pushing  strongly 
back  upon  his  forehead.  This  manoeuvre  lifts  the  hyoid 
bone,  and  with  it  the  epiglottis.  The  epiglottis  can  be  lifted 
by  passing  a  spoon-handle  over  the  dorsum  to  the  base  of 
the  tongue  and  pressing  forward.  If,  in  obstruction  to  res- 
piration, the  above  means  fail,  make  artificial  respiration  at 
once ;   '\i  obstruction  continues,  perform  tracheotomy. 

After  stopping  the  anaesthetic  in  an  ordinary  case  have 
the  patient  carefully  watched  until  consciousness  and  intelli- 
gence are  entirely  restored.  The  face  is  washed  with  cold 
water ;  the  patient  is  kept  recumbent ;  if  vomiting  occurs, 
his  head  is  hung  over  the  edge  of  the  bed  and  the  mouth  is 
subsequently  wiped  out.  No  food  should  be  taken  for  at  least 
eight  hours.  If  vomiting  occurs,  draughts  of  liot  water  will 
relieve  it  by  washing  out  the  mucus  from  the  stomach. 

Primary  Anaesthesia. — Instruct  the  patient  to  count  out 
aloud  and  to  hold  one  arm  above  his  head.  Give  the  anaes- 
thetic. In  a  short  time  he  becomes  mixed  in  his  count  and 
his  arm  sways  or  drops  to  the  side.  There  is  now  a  period 
of  insensibility  to  pain  lasting  only  about  half  a  minute,  and 
during  this  period  a  minor  operation  can  be  performed.  The 
patient  quickly  reacts  without  vomiting  from  primary  anaes- 
thesia (Packard). 

Local  Anaesthesia. — Freezing  with  Ice  and  Salt. — Take 
one-quarter  of  a  pound  of  ice,  wrap  it  in  a  towel,  and  break 
it  into  fine  bits  ;  add  one-eighth  of  a  pound  of  salt ;  then 
place  the  mixture  in  a  gauze  bag  and  lay  it  upon  the  part. 
The  surface  becomes  pallid  and  numb,  and  in  about  fifteen 
minutes  is  decidedly  analgesic.  Spray  of  rhigolene  freezes 
43 


674  ^    MANUAL    OF  SURGERY. 

in  about  ten  seconds.  It  is  highly  inflammable.  Chloride 
of  ethyl  comes  in  hermetically-sealed  glass  tubes.  Break 
the  end  of  the  tip  of  the  tube  and  hold  the  bulb  in  the 
palm  :  the  warmth  of  the  hand  causes  the  fluid  to  spray 
out.  Hold  the  tube  some  little  distance  from  the  part  and 
let  the  fine  spray  strike  the  surface.  The  skin  blanches  and 
whitens,  and  is  ready  for  the  operation  in  about  thirty 
seconds.  Ether-spray  anaesthesia  was  suggested  by  Benja- 
min Ward  Richardson. 

Cocaine  Hydro  chlorate. — Always  bear  in  mind  that 
cocaine  is  more  dangerous  than  ether  (Richardiere  made 
eleven  autopsies  in  deaths  from  cocaine).  Never  use  over 
two-thirds  of  a  grain  upon  a  mucous  surface,  and  never 
inject  hypodermatically  more  than  one-third  of  a  grain. 
The  urethra  is  a  particularly  dangerous  region,  and  so 
is  the  face.  Mild  cases  of  cocaine-poisoning  are  character- 
ized by  great  tremor,  restlessness,  pallor,  dry  mouth,  talka- 
tiveness, and  weak  pulse.  In  severe  cases  there  is  syncope 
or  delirium.  Death  may  arise' from  paralysis  or  from  fixation 
of  the  respiratory  muscles  (Mosso).  Cases  with  a  tendency 
to  respiratory  failure  require  the  hypodermatic  injection 
of  strychnine.  In  cases  with  tetanic  rigidity  of  muscles 
give  enemata  of  chloral,  hypodermatic  injections  of  nitro- 
glycerin, or  inhalations  of  the  nitrite  of  amyl.  In  cases 
marked  by  delirium,  if  the  circulation  is  good  give  chloral 
or  hyoscine.  In  any  case  give  stimulants,  employ  a  catheter, 
and  favor  diuresis.  Cocaine-poisoning  is  always  followed  by 
a  wakeful  night.  Cocaine  should  not  be  used  if  the  kidneys 
are  inefficient.  In  using  cocaine  try  to  prevent  poisoning. 
Have  the  patient  recumbent.  One  minute  before  giving  the 
cocaine,  administer  one  drop  of  a  I  per  cent,  alcoholic  solution 
of  trinitrine,  repeating  the  dose  once  or  twice  during  the 
operation.  In  operation  on  a  finger,  after  making  the  part 
anaemic  tie  a  tube  around  the  root  of  the  digit  before  inject- 


BURNS  AND   SCALDS.  675 

ing  cocaine,  and  after  the  operation  gradually  loosen  the 
tube.  Merck  prepares  a  far  safer  agent  than  the  hydro- 
chlorate,  and  that  is  the  phenate  of  cocaine.  This  is  a 
honey-like  material,  soluble  in  alcohol.  It  is  used  locally 
in  from  5  to  10  per  cent,  solutions.  It  takes  longer  to 
act  than  does  the  hydrochlorate,  and  it  coagulates  the  tissue- 
albumin,  and  thus  absorption  is  lessened.  It  causes  anaemia, 
anaesthesia,  and  retards  germ-growth  (Kyle).  Gliack  and 
Barthalow  some  time  ago  advised  a  mixture  composed  of 
cocaine  hydrochlorate  and  carbolic  acid. 


XXIX.  BURNS  AND  SCALDS. 

Burns  and  scalds  are  injuries  due  to  the  action  of  caloric. 
Scalds  are  due  to  heated  fluids  or  vapors.  There  is  no  true 
pathological  difference  between  burns  and  scalds.  Dupuy- 
tren  classifies  burns  into  six  degrees,  as  follows  :  (i)  charac- 
terized by  erythema  ;  (2)  characterized  by  dermatitis  with  the 
formation  of  vesicles  ;  (3)  characterized  by  partial  destruction 
of  the  skin,  which  structure  is  not,  however,  entirely  burnt 
through ;  (4)  characterized  by  destruction  of  the  skin  to  the 
subcutaneous  tissue ;  (5)  characterized  by  destruction  of  all 
superficial  structures  and  of  part  of  the  muscular  layer; 
(6)  characterized  by  "  carbonization  "  of  the  whole  thickness 
of  the  muscles. 

The  symptouis  are  local  and  constitutional.  Local  symp- 
toms are  pain  and  inflammation,  which  vary  in  nature,  in 
intensity,  or  in  degree  according  to  the  extent  of  damage 
done.  Constitutional  symptoms  are  shock,  followed  by  a 
severe  reactionary  fever,  with  a  strong  tendency  to  con- 
gestion of  internal  parts.  Sepsis  is  not  infrequent.  The 
stages  are  often  designated  as  prostratioii,  reaction^  and  sup- 
puration.    Death  may  be  due  to  shock,  to  sepsis,  to  exhaus- 


676  A   MANUAL    OF  SURGERY. 

tion,  to  congestion  of  the  brain,  lungs,  or  kidneys,  or  to 
Curling's  ulcer  of  the  duodenum. 

Treatment. — The  local  treatment  of  slight  burns  (as  sun- 
burn) is  to  wrap  up  the  parts  in  a  saturated  solution  of 
bicarbonate  of  soda,  a  strong  solution  of  Epsom  salt,  or 
a  I  :  8  solution  of  phenol  sodique.  In  burns  of  moderate 
degree  a  mixture  of  zinc  ointment  with  iodoform,  though 
not  antiseptic,  is  a  comfortable  dressing ;  but  all  severe 
burns  should  be  treated  antiseptically.  In  a  severe  burn, 
cut  away  the  clothing,  avoid  exposure  to  cold,  wash  the 
part  with  a  solution  of  peroxide  of  hydrogen  and  then  with 
a  warm  solution  of  boracic  acid,  open  the  vesicles  with  an 
aseptic  needle,  dust  on  iodoform,  and  dress  with  aseptic 
cotton.  Change  the  dressings  no  oftener  than  is  required, 
and  at  each  change  wash  the  burn  with  peroxide  af  hydro- 
gen and  boracic  acid,  take  away  sloughs,  and  reapply  iodo- 
form and  cotton.  Where  extensive  destruction  of  tissue  has 
taken  place,  use  splints  and  extension  to  limit  contractures, 
and  skin-graft  as  soon  as  possible.  If  granulation  is  slow, 
stimulate  with  copper-sulphate  or  mild  silver-nitrate  solu- 
tions. Exuberant  granulations  require  burning  down.  Flabby 
granulations  require  pressure.  Carron  oil,  which  consists  of 
linseed  oil  and  lime-water,  allays  the  pain  of  a  burn,  but  it  is 
a  foul  and  dirty  preparation.  When  an  extremity  has  been 
carbonized  amputation  must  be  performed.  In  constitu- 
tional treatment,  react  from  shock ;  combat  pain  with  opium  ; 
keep  the  bowels  and  kidneys  active.  If  suppuration  occurs, 
give  tonics,  stimulants,  and  concentrated  foods.  Complica- 
tions are  treated  according  to  general  rules. 

Scalds  of  the  glottis  are  due  to  the  inhalation  of  steam 
or  of  ignited  gas.  A  child  may  scald  the  glottis  by  trying 
to  drink  from  the  spout  of  a  kettle  (Moullin).  The  symptoms 
are  pain,  dysphagia,  and  dyspnoea.  GEdema  of  the  glottis 
quickly  comes  on.     The  treatment  is  tracheotomy  or  intuba- 


BURNS  AND   SCALDS.  6^^ 

tion  of  the  larynx  in  severe  cases ;  in  mild  cases,  scarifica- 
tion of  the  larynx. 

Effects  of  Cold. — Local  Effects. — Cold  produces  numb- 
ness, prickling,  a  feeling  of  weight,  redness  of  the  surface 
followed  by  stiffness,  local  insensibility,  and  mottling  or  pal- 
lor. Sudden  intense  cold  causes  the  formation  of  blebs,  the 
coagulation  of  blood  in  the  superficial  veins,  and  violent 
pain  in  the  limb.  Cold  locally  produces  frost-bite  (p.  1 1 8). 
The  constitutional  effects  of  cold  are  at  first  stimulating,  then 
depressing,  and  are  exhibited  by  uneasiness,  pain,  and  an 
intense  drowsiness  which,  if  yielded  to,  is  the  road  to  death 
by  way  of  internal  congestion.  Death  from  prolonged  cold 
resembles  in  appearance  death  from  apoplexy.  Death  from 
sudden  and  overwhelming  cold  is  caused  by  anaemia  of  the 
brain  from  weak  circulation  and  capillary  embolism.  To 
bring  a  partly-frozen  person  into  a  warm  room  will  cause 
death  by  embolism. 

Treatment. — Frost-bite  is  treated  as  outlined  on  page  ii8. 
When  a  person  is  nearly  frozen  to  death,  place  him  in  a  cool 
room,  but  under  no  circumstance  in  a  cold  bath,  make  arti- 
ficial respiration,  rub  him  down  with  flannel  soaked  in  alcohol 
or  in  whiskey,  and  follow  this  by  rubbing  with  dry  hands. 
After  a  time  wrap  the  patient  in  warm  blankets  and  give  an 
enema  of  brandy.  Mustard  plasters  are  to  be  applied  over 
the  heart  and  spine.  As  soon  as  swallowing  is  possible 
brandy  is  administered  by  the  mouth.  As  the  condition 
improves  gradually  raise  the  temperature  of  the  room  and 
give  hot  drinks. 

Chilblain,  or  pernio,  is  the  secondary  effect  of  cold.  It 
usually  appears  as  a  local  congestion  upon  the  toes,  the 
fingers,  or  the  nose,  and  it  is  apt  now  and  then  to  inflame 
and  ulcerate.  A  chilblain  is  apt  to  become  congested  by 
approaching  a  fire  or  by  taking  exercise,  and  when  con- 
gested it  itches,  tingles,  and  stings.      Frequent  attacks  of 


6yS  A   MANUAL    OF  SURGERY. 

congestion  produce  crops  of  vesicles ;  these  vesicles  rupture 
and  expose  an  ulcer  which  in  rare  instances  sloughs. 

Treatment. — Prevent  congestion  of  the  legs  and  feet  if 
chilblain  affects  the  toes.  Order  large  shoes  and  woollen 
stockings  and  forbid  tight  garters.  The  patient  with  pernio 
must  take  regular  outdoor  exercise  and  must  not  loiter 
around  a  hot  fire.  Every  morning  and  evening  he  should 
take  a  general  cold  sponge  bath  followed  by  rubbing  with 
alcohol  and  frictions  with  a  coarse  towel,  and  he  should 
sleep  with  warm  stockings  on  or  with  his  feet  upon  a  hot- 
water  bag.  When  a  chilblain  is  only  a  congested  spot  it 
should  be  washed  twice  a  day  in  cold  salt  water,  rubbed  dry 
with  flannel,  and  subjected  to  applications  of  tincture  of 
iodine  and  soap  liniment  (i  :  2),  tincture  of  cantharides  and 
soap  liniment  (i  :  6),  or  equal  parts  of  turpentine  and  olive 
oil  (W.  H.  A.  Jacobson).  Jacobson  says  itching  is  relieved 
by  painting  belladonna  liniment  upon  the  part  and  allowing 
it  to  dry.  If  vesicles  form,  paint  with  contractile  collodion  ; 
if  ulcers  form,  dress  antiseptically.  If  ulcers  are  sluggish, 
use  equal  parts  of  resin  cerate  and  spirits  of  turpentine.  A 
good  antiseptic  and  protective  is  the  following :  Oxide  of 
zinc,  grs.  vj ;  chloride  of  zinc,  gr.  xx ;  gelatin,  ^ij  ;  Dis- 
tilled water,  sj. 

XXX.    DISEASES  OF  THE   SKIN  AND  NAILS. 

Dermatitis  venenata  results  from  irritants  and  from  gar- 
ments containing  arsenic,  but  is  generally  due  to  rhus-poi- 
soning.  Rhus-poisoning  arises  from  the  poison-oak,  the 
poison-ash,  the  poison-ivy,  and  other  species  of  sumach. 
Actual  touching  of  the  plants  is  not  always  necessary.  The 
symptoms  are  burning  and  itching,  redness  and  oedema  of 
the  face  and  hands.  A  vesicular  eruption  begins  between 
the  fingers,  and  the  eruption  and  the  inflammation  spread 


DISEASES   OF  THE   SKIN  AND   iVAILS.  679 

widely  over  the  body.  There  may  be  some  slight  fever^ 
The  treatment,  when  a  moderate  area  is  involved,  com- 
prises the  application  of  cloths  wet  with  black  wash  or  lead- 
water  and  laudanum.  If  an  extensive  area  is  involved,  apply 
grindelia  robusta  (3iv  to  Oj  of  water)  or  moisten  the  surface 
frequently  with  sweet  spirits  of  nitre.  For  the  face  use 
borated-talc  powder.  Oxide-of-zinc  ointment  containing  10 
grs.  of  carbolic  acid  to  ^j  gives  great  relief.  A  i  :  8  solu- 
tion of  phenol  sodique  allays  pain  and  itching. 

Furuncle,  or  boil,  is  an  acute  and  circumscribed  inflam- 
mation and  suppuration  of  a  hair-follicle,  a  sebaceous  gland, 
and  the  adjacent  connective  tissue.  A  boil  is  caused  by  in- 
fection of  a  hair-follicle,  through  a  slight  wound  (by  scratch- 
ing, shaving,  etc.),  with  the  staphylococcus  pyogenes  aureus. 
Boils  are  very  common  during  Bright's  disease,  diabetes, 
gout,  tuberculosis,  and  disorders  of  menstruation  and  diges- 
tion. Boils  are  commonest  in  the  spring,  and  sometimes  an 
epidemic  of  furunculosis  appears  in  a  hospital,  a  jail,  or  an 
asylum.  The  symptoms  of  a  boil  are  as  follows :  A  red 
elevation  appears,  which  stings  and  itches ;  this  elevation 
enlarges  and  becomes  dusky  in  color ;  a  pustule  forms,  that 
ruptures  and  gives  out  a  very  little  discharge  which  forms  a 
crust.  Inflammatory  infiltration  of  adjacent  connective  tissue 
advances  rapidly,  and  the  boil  in  about  three  days  consists 
of  a  large,  red,  tender,  and  painful  base  capped  by  a  pustule 
and  some  crusted  discharge.  In  rare  instances,  at  this 
stage,  absorption  occurs,  but  in  most  cases  the  swelling 
increases,  the  discoloration  becomes  dusky,  the  skin  becomes 
oedematous,  the  pain  becomes  fierce  and  pulsatile,  and  the 
centre  of  the  boil  becomes  lifted  up.  About  the  seventh 
day  rupture  occurs,  pus  runs  out,  and  a  **  core  "  of  necrosed 
tissue  is  found  in  the  centre  of  a  ragged  opening.  In  a  day 
or  two  more  the  core  will  be  discharged  and  healing  by 
granulation  will  occur.     A  blifid  boil  lasts  only  three  or  four 


68o  A    MANUAL    OF  SURGERY. 

days  and  has  no  core.  Tlie  constitution  often  shows  reaction 
during  the  progress  of  a  boil.  Boils  may  be  either  single  or 
multiple.  The  development  of  boil  after  boil  is  known  as 
"  furunculosis."  Boils  are  commonest  upon  the  neck  and 
the  back.  The  treatment  consists  of  crucial  incision,  re- 
moval of  necrotic  tissue,  irrigation  with  peroxide  of  hydro- 
gen and  corrosive  sublimate,  and  antiseptic  dressing. 

Aleppo  boils  (endemic  boils  of  the  tropics)  are  papules 
appearing  upon  the  exposed  parts  of  the  body.  These 
papules,  which  ulcerate  and  do  not  cicatrize  for  at  least  a 
year,  are  due  to  a  pathogenic  bacterium  and  leave  ineradi- 
cable scars. 

Carbuncle  (benign  anthrax)  is  a  circumscribed  infectious 
inflammation  of  the  deeper  layer  of  the  true  skin  and  of  the 
subcutaneous  tissue,  with  fibrinous  exudation  in  which 
multiple  foci  of  necrosis  arise  and  the  tissue  adjacent  to 
each  necrotic  plug  becomes  gangrenous.  The  infection 
takes  place  through  a  hair-follicle.  It  is  really  a  boil  with 
extensive  infiltration  of  adjacent  tissues.  A  boil  can  become 
a  carbuncle,  and  pus  from  a  carbuncle  inoculated  into  a 
healthy  person  may  cause  either  a  boil  or  a  carbuncle. 
The  causative  organism  seems  to  be  the  staphylococcus 
pyogenes  aureus.  The  local  symptoms  in  the  start  resemble 
those  of  a  boil,  but  the  constitution  sympathizes  from  the 
beginning  (a  chill  and  a  septic  fever)  and  the  pain  is  agoniz- 
ing. The  inflammatory  area  enlarges  enormously,  is  boggy 
to  the  touch,  is  dusky  in  color,  is  oedematous,  and  the  skin 
is  not  freely  movable  over  the  deeper  parts.  In  a  i^v^  days 
many  pustules  appear,  each  pustule  marking  the  site  of  a 
focus  of  necrosis.  Large  vesicles  filled  with  bloody  serum 
are  frequently  met  with.  In  some  cases,  about  the  tenth 
day,  the  pustules  rupture,  the  necrotic  plugs  are  discharged, 
and  the  case  slowly  progresses  toward  cure ;  but  in  many 
cases  the  carbuncle  spreads  at  the  periphery  while  pustules 


DISEASES   OF   THE   SKIN  AND  NAILS.  68 1 

are  rupturing  near  the  centre  of  inflammation,  and  pus  forms 
in  the  deeper  tissues,  reaching  the  surface  through  many 
small  openings  each  of  which  is  partly  blocked  by  a  plug 
of  dead  tissue.  A  carbuncle  in  this  stage  resembles  a 
honeycomb,  discharges  bloody  pus,  and  large  masses  of 
skin  and  subcutaneous  tissue  are  destroyed.  The  entire 
carbuncular  mass  may  become  gangrenous,  and  a  sudden 
and  almost  complete  cessation  of  pain  points  to  this  compli- 
cation. An  ordinary  carbuncle  remains  acute  for  about 
three  weeks,  but  healing  requires  a  month  more.  The 
most  dangerous  positions  for  a  carbuncle  are  the  face  and 
neck  (tends  to  produce  septic  phlebitis,  septic  clots  in  the 
cerebral  sinus,  or  infective  emboli).  The  most  usual  positions 
for  carbuncle  are  the  neck,  the  back,  and  the  buttocks.  The 
diagnosis  of  carbuncle  is  made  by  noting  the  multiple  foci  of 
necrosis  and  the  profound  constitutional  involvement. 

Treatment. — Give  ether,  make  free  crucial  incisions,  re- 
move dead  and  necrosing  tissue  with  the  scissors  and 
forceps,  curette  pockets,  stop  hemorrhage  by  pressure  and 
hot  water,  cauterize  with  pure  carbolic  acid,  dust  with  iodo- 
form, pack  with  iodoform  gauze,  and  dress  with  corrosive- 
sublimate  gauze.  Every  day,  or  several  times  a  day,  remove 
the  dressings,  wash  with  peroxide  of  hydrogen,  irrigate  with 
corrosive-sublimate  solution,  dust  in  iodoform,  and  reapply 
the  iodoform  gauze  and  antiseptic  gauze.  Secure  sleep  by 
morphia,  give  quinine,  milk  punch,  and  nourishing  diet,  and 
attend  to  the  bowels  and  kidneys. 

Clavus,  or  Corn. — A  corn  is  a  tender,  painful,  and  cir- 
cumscribed thickening  of  the  epidermis,  and  is  commonest 
over  one  of  the  joints  of  the  toes.  Hard  corns  are  situated 
on  exposed  parts  of  the  digits  ;  soft  corns  appear  between 
the  digits  and  are  kept  constantly  moist.  Corns  are  caused 
by  pressure. 

Treatnieiit. — By  wearing  well- fitting  boots  corns  upon  the 


682  A   MANUAL    OF  SURGERY. 

toes  will  usually  disappear.  Soak  the  feet  often  in  water 
containing  bicarbonate  of  soda,  dry  them,  and  apply  circular 
corn-plasters  to  the  corn,  to  take  off  the  pressure  of  the  boot. 
Another  method  is  to  touch  the  corn  with  iodine  every 
night  and  pare  away  the  hard  tissue  every  morning.  An  old 
and  valuable  plan  is  to  paint  the  corn  every  night  with  a 
mixture  composed  of  salicylic  acid,  3iss ;  extract  of  cannabis 
indica,  grs.  x;  and  collodion,  .^j,  and  to  scrape  this  mixture 
away  every  morning.  Soft  corns  are  treated  by  washing 
the  feet  often  with  ethereal  soap,  drying,  gently  removing 
the  soft  epithelium,  dusting  with  borated  talc,  and  placing 
absorbent  cotton  between  the  toes.  Incurable  soft  corns  re- 
quire the  freshening  of  the  adjacent  sides  of  the  two  toes  and 
suturing  them  together  (thus  converting  two  toes  into  one). 
In  inflamed  corns  employ  rest  and  lead-water  and  laudanum, 
and  let  out  pus  when  it  forms.  Remember  that  in  old  per- 
sons the  cutting  of  a  corn  may  cause  senile  gangrene.  In 
the  inflamed  and  painful  feet  of  a  person  who  has  corns, 
nothing  gives  so  much  relief  as  washing  them  with  ethereal 
soap,  soaking  in  hot  water,  and  wrapping  the  feet  for  half  an 
hour  in  cloths  wet  with  a  mixture  composed  of  linseed  oil 
and  lime-water,  each,  ,lij,  and  spirits  of  camphor,  3J. 

Warts. — (See  p.  215.) 

Onychia  is  inflammation  of  the  matrix  of  the  nail.  A 
"  run-around  "  is  suppuration  of  the  matrix  and  the  root  of 
the  nail,  of  traumatic  origin.  It  requires  incision,  trimming 
away  of  the  buried  edge  of  the  nail,  and  packing  with  iodo- 
form gauze.  Malignant  onychia,  which  is  inflammation  and 
ulceration  of  the  entire  matrix,  occurs  in  persons  with  di- 
lapidated constitutions.  This  condition  requires  removal  of 
the  entire  nail,  cauterization  of  the  matrix,  dressing  with 
iodoform  gauze,  and  the  internal  use  of  stimulants,  tonics, 
and  nourishing  diet.  Ingrown  toe-nail  is  due  either  to 
lateral  hypertrophy  of  the  edge  of  the  nail  or  to  the  forcing 


DISEASES  AXD   IXJ CRIES   OF  THE    LYMPHATICS.      683 

of  the  soft  tissues  over  the  margin  of  the  nail.  The  con- 
dition is  treated  by  sphtting  the  nail,  removing  the  piece  of 
nail,  the  soft  tissue,  and  the  adjacent  matrix,  and  dressing 
antiseptically. 


XXXI.    DISEASES    AND    INJURIES    OF    THE 
LYMPHATICS. 

Lymphangitis  is  inflammation  of  lymphatic  vessels.  Re- 
ticular lymphangitis,  which  is  inflammation  of  lymphatic 
radicals,  is  seen  in  some  circumscribed  inflammations  of  the 
skin.  It  is  apt  to  attack  the  hands,  causing  redness  and 
swelling,  fading  at  the  point  of  initial  trouble  while  it  spreads 
at  the  periphery;  it  is  caused  by  micro-organisms  derived 
from  decomposing  animal  matter  (Rosenbach).  Erysipelas 
also  causes  it  (see  Erysipelas).  Tubular  lymphangitis,  which 
is  due  to  the  entry  into  the  lymphatic  ducts  of  virulent  micro- 
organisms or  their  products,  is  seen  in  dissection-wounds, 
septic  wounds,  snake-bites,  etc.  It  is  announced  by  oedema 
and  by  minute  hard  red  streaks  running  from  the  wound  up 
the  extremity.     Suppuration  may  occur. 

Lymphadenitis,  or  inflammation  of  the  glands,  may  follow 
lymphangitis  or  may  be  due  to  the  deposition  of  infective 
material,  the  lymph-vessels  not  being  inflamed.  In  septic 
lymphadenitis  there  are  pain,  tenderness,  and  swelling.  In 
severe  cases  there  are  chill  and  septic  fever.  Suppuration 
may  arise.  The  treatment  is  to  drain  and  asepticize  the 
wound,  to  apply  over  the  glands  and  vessels  iodine  and  blue 
ointment  or  ichthyol,  and  to  employ  rest  and  compression. 
Internally,  milk  punch,  quinine,  and  nourishing  diet  are 
required.     If  suppuration  occurs,  incise  and  drain. 

Acute  lymphadenitis,  or  acute  inflammation  of  lymphatic 
glands,  may  follow  lymphangitis  or  may  be  due  to  tubercle, 
syphilis,  glanders,  cold,  or  traumatism.     Suppuration  may  or 


684  ^   MANUAL    OF  SURGERY. 

may  not  occur.  In  inflammatory  lymphadenitis  there  are 
pain,  heat,  and  nodular  swelling.  In  severe  cases  there  is 
fever.  The  treatment  is  to  asepticize  any  area  of  infection, 
place  the  glands  at  rest,  apply  cold  and  lead-water  and  lauda- 
num, or  inject  into  the  gland  every  day  5  m.  of  a  3  per  cent, 
solution  of  carbolic  acid  to  prevent  suppuration.  If  pus 
forms,  evacuate,  drain,  and  asepticize. 

Chronic  adenitis  is  almost  invariably  syphilitic  or  tuber- 
cular. It  requires  constitutional  treatment  and  the  local  use 
of  ichthyol,  iodine,  or  blue  ointment. 

Lymphangiectasis  (varicose  lymphatics),  or  dilatation  of 
the  lymphatic  vessels,  is  due  to  obstruction.  It  results,  as  a 
rule,  from  chronic  lymphangitis  or  the  pressure  of  a  tumor, 
and  is  most  usually  situated  in  the  pubic,  the  inguinal,  or  the 
scrotal  regions  or  on  the  inner  side  of  the  thigh.  There  are 
two  forms :  the  varicose,  in  which  the  vessels  have  a  tortuous 
outline,  like  varicose  veins,  but  are  covered  only  by  surface 
epithelium ;  and  lyinpliatic  warts  (lymphangioma  circum- 
scriptum), in  which  wart-like  masses  spring  up,  these  masses 
being  covered  with  epithelium  and  filled  with  lymph.  In 
most  cases  of  lymphangiectasis  there  is  considerable  hard 
oedema.  Rupture  of  the  dilated  vessel  causes  a  flow  of  lymph 
{lympJiorrJwed) . 

Lymphangioma  is  an  advanced  stage  of  lymphangiectasis 
(p.  209).  The  treatment  in  mild  cases  is  to  pierce  each  ves- 
icle with  the  minus  pole  of  a  galvanic  battery  and  pass  a 
current.  In  severe  cases  destroy  the  mass  with  the  Pacque- 
lin  cautery  or  excise  it  with  a  knife  or  with  scissors. 

Elephantiasis. —  Trtie  elephantiasis  (elephantiasis  Arabum) 
is  chronic  hypertrophy  of  the  skin  and  subcutaneous  tissues 
following  upon  a  lymphangiectasis  produced  by  a  nematode 
worm  (the  filaria  sanguinis  hominis).  Spurious  elephantiasis 
is  hypertrophy  of  the  skin  and  subcutaneous  tissue  due  to 
chronic  inflammation'  (in  a  leg  which  possesses  an  ancient 


B  AX D  AGES.  685 

ulcer,  or  in  the  scrotum  of  a  man  with  urinary  fistula).  The 
treatment  is  massage  and  bandaging,  sometimes  ligation  of 
the  artery  of  supply,  extirpation,  or  amputation. 

Malig-nant  Lymphoma,  or  Hodgkin's  Disease. — (See 
P-  203). 

XXXII.   BANDAGES. 

A  bandage  is  a  fibrous  material  which  is  rolled  up  and  is 
then -employed  to  retain  dressings,  applications,  or  appliances 
to  a  part,  to  make  pressure,  or  to  correct  deformity.  It  may 
be  made  of  plain  gauze,  of  gauze  infiltrated  with  plaster  of 
Paris  or  soaked  in  silicate  of  sodium,  of  gauze  wet  with 
corrosive-sublimate  solution,  of  flannel,  of  calico,  or  of  un- 
bleached muslin.  Unbleached  muslin,  which  is  the  best 
material  for  general  use,  is  washed  to  remove  the  sizing, 
is  torn  into  strips,  and  the  edges  are  stripped  of  selvage. 
One  end  is  folded  to  the  extent  of  six  inches,  this  is  folded 
upon  itself  again  and  again  until  a  firm  centre  is  formed, 
and  over  this  centre  the  bandage  is  rolled.  In  a  well-rolled 
bandage  the  centre  cannot  be  pushed  out  of  the  roll. 

A  eylindrical  part  of  the  body  may  be  covered  by  a  cir- 
r?//^r  bandage,  each  turn  exactly  covering  the  previous  turns. 
A  conical  part  may  be  covered  by  a  spiral  bandage,  each  turn 
ascending  a  little  higher  than  the  previous  turn.  As  each  turn 
of  a  spiral  bandage  is  tight  at  its  upper  and  loose  at  its  lower 
edge,  the  reverse  was  devised  to  correct  this  inequality; 
hence  a  conical  part  should  be  covered  by  a  spiral  reversed 
bandage.  To  make  a  reverse  hold  the  roller  in  the  right  hand 
(do  not  have  more  than  six  inches  of  slack),  place  the  thumb 
across  the  fresh  turn,  fold  the  bandage  down  without  traction, 
and  do  not  make  traction  until  the  turn  has  been  carried 
well  around  the  limb.  A  projecting  point  is  covered  with 
figure-of-8  turns.  The  groin,  shoulder,  breast,  or  axilla  can 
be  covered  by  figure-of-S  turns,  each  succeeding  turn  ascend- 


686  A   MANUAL    OF  SURGERY. 

ing  and  covering  two-thirds  of  the  previous  turn  and  form- 
ing a  figure  like  "the  leaves  on  an  ear  of  corn."  Such  a 
figure  is  called  a  "  spica."  In  bandaging  an  extremity  the 
peripheral  turns  should  be  tighter  than  the  turns  nearer  the 
body.  Never  apply  a  tight  bandage  to  the  leg  or  the  arm 
without  including  the  foot  or  the  hand.  In  firm  dressings 
leave  the  fingers  exposed,  and  use  them  as  an  index  of  the 
condition  of  the  circulation  in  the  part. 

Spiral  Reversed  Bandage  of  the  Upper  Extremity. — In 
making  this  form  of  bandage,  use  a  roller  two  and  a  half 
inches  wide  and  eight  yards  long.  Take  a  circular  turn 
about  the  wrist,  and  a  second  turn  to  hold  the  first ;  pass 
obliquely  across  the  back  of  the  hand  to  the  extremities  of 
the  fingers ;  ascend  the  hand  to  the  root  of  the  thumb  by 
several  spiral  turns  ;  cover  the  wrist  by  a  figure-of-8  ;  ascend 
the  forearm  by  spiral  reversed  turns ;  cover  the  elbow  b}^  a 
figure-of-8,  and  the  arm  by  spiral  reversed  turns ;  end  the 
bandage  by  two  circular  turns,  and  pin  them  (PI.  1 1,  Fig.  4). 

Spiral  Bandag-e  of  All  the  Fingers  (Gauntlet). — The 
gauntlet  bandage  requires  a  roller  one  inch  wide  and  one 
and  a  half  yards  long.  Take  two  circular  turns  around  the 
wrist,  pass  obliquely  across  the  wrist  to  the  root  of  the  thumb, 
and  descend  to  its  tip  by  spiral  turns ;  cover  in  the  thumb 
by  spiral  reverses,  and  return  to  the  wrist.  Cover  in  each 
successive  finger  in  the  same  manner,  and  terminate  by  two 
circular  turns  around  the  wrist  (PI.  1 1,  Fig.  2). 

Spiral  Bandage  of  the  Palm  or  Dorsum  of  the  Hand 
(Demi-gauntlet). — The  demi-gauntlet  requires  a  roller  one 
inch  wide  and  four  yards  long.  This  bandage  has  only  a 
limited  value ;  it  must  not  be  applied  tightly,  as  it  makes 
much  pressure  at  the  finger-roots,  but  leaves  the  fingers  free. 
If  it  is  desired  to  cover  the  palm,  supinate  the  hand  ;  if  to 
cover  the  dorsum,  pronate  the  hand.  Take  two  circular  turns 
around  the  wrist,  sweep  around  the  root  of  the  thumb,  and 


BANDAGING. 


Plate  io. 


1  Oblique  or  Crossed  Bandage  of  the  Angle  of  the  Jaw  ;  2,  Gibson's  Bandage ;  3,  Recurrent 
Bandage  of  the  Head;  4,  Crossed  Figure-of-8  Bandage  of  both  Eyes;  5,  Barton's  Bandage  or 
Figure-of-S  of  the  Jaw :  6,  Figure-of-8  Bandage  of  the  Elbow. 


BANDAGES.  68/ 

return  to  the  point  of  origin.     Treat  each  finger  in  the  same 
way.     End  by  circular  turns  around  the  wrist  (PI.  1 1,  Fig.  i). 

Spica  of  the  Thumb. — For  this  bandage  use  a  roller  one 
inch  wide  and  three  yards  long.  Start  at  the  wrist,  and 
reach  the  tip  of  the  thumb  as  in  applying  a  spiral  bandage 
of  a  finger.  Make  a  series  of  ascending  figure-of-8  turns 
between  thumb  and  wrist,  each  ascending  turn  overlying 
two-thirds  of  the  previous  turn ;  terminate  with  a  circular 
of  the  wrist  (PL  ii,  Fig.  3). 

Spiral  Reversed  Bandag-e  of  the  Lower  Extremity. — 
Take  a  roller  two  and  a  half  inches  wide  and  seven  yards 
long,  and  make  two  circular  turns  just  above  the  malleoli, 
and  an  oblique  turn  across  the  dorsum  of  the  foot  to  the 
metatarso-phalangeal  articulation ;  make  a  circular  turn,  and 
cover  the  foot  with  spiral  reversed  turns  ;  return  to  the  ankle 
by  a  figure-of-8 ;  ascend  the  leg  by  spiral  reverses ;  cover 
the  knee  by  a  figure-of-8,  and  the  thigh  by  spiral  reverses ; 
terminate  by  two  circular  turns  (PL  ii.  Fig.  6). 

Bandage  of  the  Foot  covering  the  Heel  (American 
Bandage  of  the  Foot). — Take  a  roller  two  and  a  half  inches 
wide  and  seven  yards  long.  The  bandage  is  begun  as  is 
a  spiral  reversed  bandage  of  the  lower  extremity.  After  the 
foot  is  well  covered  by  ascending  spiral  reversed  turns,  carry 
the  bandage  directly  around  the  point  of  the  heel  and  return 
to  the  instep ;  from  this  point  carry  it  around  the  back  of 
the  ankle,  down  the  side  of  the  heel,  under  the  heel  to  the 
instep,  around  the  ankle  in  the  opposite  direction,  down  the 
opposite  side  of  the  heel,  and  under  the  heel  to  the  instep ; 
take  the  roller  to  above  the  malleoli,  and  end  by  a  circular 
turn  (PL  12,  Fig.  2). 

Bandag-e  of  the  Foot  not  covering  the  Heel  (French 
Method). — Take  a  roller  two  and  a  half  inches  wide  and 
six  yards  long.  Make  a  spiral  reversed  bandage  of  the  foot 
and  a  figure-of-8  of  the  ankle-joint  (PL  12,  Fig,  i). 


688 


A   MANUAL    OF  SURGE KY. 


Spiral  Bandag-e  of  the  Foot  covering-  the  Heel  (Kibble's 
Bandage ;  Spica  of  the  Instep). — Take  a  roller  two  and  a 
half  inches  wide  and  six  yards  long.  Apply  as  a  spiral 
reversed  bandage  of  the  lower  extremity  until  the  meta- 
tarsus is  well  covered.  Carry  the  bandage,  parallel  with  the 
margin  of  the  foot  (the  inner  or  outer  margin,  according  as 
to  whether  it  is  the  left  foot  or  the  right),  around  the  poste- 
rior aspect  of  the  heel,  along  the  opposite  margin  of  the  foot 
to  cross  the  original  turn  at  the  median  line  of  the  dorsum. 
Make  a  number  of  these  ascending  turns,  each  turn  covering 
in  three-fourths  of  the  previous  turn ;  terminate  by  circular 
turns  above  the  ankle  (PL  12,  Fig.  3). 

Crossed  Bandage  of  Both  Byes  (Figure-of-8  of  Both 
Eyes). — Take  a  roller  two  inches  wide  and  six  yards  long. 
Make  a  circular  turn  around  the  forehead  from  right  to  left, 
a  second  turn  to  hold  the  first,  a  turn  downward  over  the 
left  eye,  under  the  left  ear,  around  the  back  of  the  neck, 

A  B 


Fig.  170. — Borsch's  Eye-bandage:  a,  first  step;  b,  second  step. 

and  upward  under  the  right  ear  and  over  the  right  eye ; 
repeat  these  turns,  and  terminate  by  a  circular  turn  of  the 
forehead  (PI.  10,  Fig.  4). 

Borsch's    eye-bandage    is    convenient   and    useful    (Fig. 
170). 


BANDAGING. 


Plate  ii. 


I.  Demi-gauntlet  Bandage;  2,  Gauntlet  Bandage;  3,  Spica  of  the  Thumb;  4,  Spiral  Reverse 
Bandage  of  the  Upper  Extremity  ;  5,  Recurrent  Bandage  of  Stumps;  6,  Spiral  Reverse  Bandage 
of  the  Lower  Extremity. 


BANDAGES.  689 

Barton's  Bandage  (Figure-of-8  of  the  Jaw). — Take  a 
roller  two  inches  wide  and  five  yards  long.  Place  the  initial 
extremity  of  the  bandage  behind  the  inion ;  pass  over  the 
right  parietal  bone,  across  the  vertex,  down  the  left  side  in 
front  of  the  ear,  under  the  chin,  up  the  right  side  in  front 
of  the  ear,  across  the  vertex,  and  across  the  left  parietal  bone 
to  the  point  of  origin.  A  turn  is  now  taken  forward  along 
the  right  side  of  the  jaw  to  the  chin,  and  backward  along 
the  left  side  of  the  jaw,  from  the  chin  to  the  nape  of  the 
neck;  repeat  these  turns,  and  pin  the  points  of  junction 
(PL  10,  Fig.  5).  In  Barton's  bandage  the  ear  lies  in  a  tri- 
angle. The  bandage  may  be  finished  by  circular  turns 
around  the  forehead.  Barton's  bandage  is  used  for  fracture 
of  the  lower  jaw, 

Gibson's  Bandage. — Take  a  roller  two  inches  wide  and 
six  yards  long.  Make  three  vertical  turns  around  the  head 
and  the  jaw  in  front  of  the  ear;  reverse  the  bandage  above 
the  level  of  the  ear,  and  carry  it  horizontally  around  the 
forehead  and  head  three  times ;  drop  the  bandage  to  the 
nape  of  the  neck,  and  take  three  turns  around  the  neck  and 
jaw ;  terminate  by  taking  from  the  nape  of  the  neck  a  half 
turn  upward,  carrying  the  bandage  forward  to  the  forehead, 
and  pinning  it  over  the  neck  and  over  the  forehead.  Pin 
each  point  of  junction  (PL  10,  Fig.  2).  Gibson's  bandage 
is  used  for  fracture  of  the  lower  jaw. 

Crossed  Bandage  of  the  Angle  of  the  Jaw  (Oblique 
Bandage  of  the  Jaw). — Take  a  roller  two  inches  wide  and 
six  yards  long.  Make  a  circular  turn  around  the  forehead 
toward  the  affected  side,  and  a  second  turn  to  hold  the  first; 
drop  to  the  back  of  the  neck  ;  come  forward  on  the  sound 
side,  under  the  ear  and  chin  ;  now  make  a  series  of  turns 
around  the  head  and  jaw,  in  front  of  the  ear  on  the  injured 
side,  but  back  of  the  ear  on  the  sound  side  :  these  turns 
successively  advance  on  the  sound  side  only ;  terminate  by 
44 


690  A   MANUAL    OF  SURGERY. 

going  backward  under  the  ear  of  the  sound  side  to  the  nape 
of  the  neck,  and  then  by  taking  two  circular  turns  around 
the  forehead  (PL  10,  Fig.  i).  This  bandage  is  used  for  frac- 
tures of  the  ramus  of  the  jaw  and  for  holding  dressings  upon 
the  face  and  the  cranium. 

Spica  of  the  Groin  (Figure-of-8  of  the  Thigh  and  Pelvis). 
— For  one  groin  the  roller  is  three  inches  wide  and  seven 
yards  long  ;  for  both  groins,  three  inches  wide  and  ten  yards 
long.  Take  two  circular  turns,  from  right  to  left,  around 
the  waist,  then  down  over  the  front  of  the  right  groin,  around 
the  back  of  the  thigh,  up  over  the  front  of  the  right  thigh, 
around  the  waist,  down  over  the  front  of  the  left  groin, 
around  the  back  of  the  thigh,  up  over  the  left  groin,  and 
around  the  waist.  The  map  being  thus  laid  out,  the  turns 
are  continued  and  ascended,  each  turn  overlying  one-third 
of  the  previous  turn,  and  the  bandage  is  completed  by  a 
circular  turn  around  the  waist  (PL  12,  Fig.  4).  Pin  the 
crossed  pieces. 

Spica  of  the  Shoulder. — Take  a  roller  two  and  a  half 
inches  wide  and  seven  yards  long.  Make  a  circular  turn 
and  several  spiral  reversed  turns  around  the  upper  arm  ;  then, 
coming  from  behind  forward,  carry  the  bandage  over  the 
shoulder,  across  the  front  of  the  chest,  through  the  opposite 
arm-pit,  and  return  across  the  back  to  the  shoulder.  Make 
successive  and  advancing  turns  (PL  13,  Fig.  6). 

Figure-of-8  bandages  of  the  breast,  the  elbow,  the  neck 
and  axilla,  and  of  both  shoulders  (posterior  figure-of-8)  are 
shown  on  Plate  10  (Fig.  6),  Plate  12  (Figs.  5,  6),  and  Plate 
13  (Figs.  1-6). 

Velpeau's  Bandage. — Take  a  roller  two  and  a  half  inches 
wide  and  ten  yards  long.  Place  the  palm  of  the  hand  of 
the  injured  side  upon  the  shoulder  of  the  sound  side,  inter- 
posing cotton  between  the  arm  and  the  side.  Start  at  the 
axilla  of  the  sound  side  posteriorly,  cross  the  back  to  the 


BANDAGING. 


Plate  12. 


I.  Figiire-of-8  Bandage  of  the  Ankle;  2,  Method  of  Covering  the  Heel;  3,  Spica  of  the  Instep: 
4,  Spica  of  the  Groin;  5,  Posterior  Figure-of-8  of  both  Shoulders;  6,  Figure-of-8  of  Neck  and 
Axilla. 


BANDAGES.  69 1 

shoulder  of  the  injured  side,  down  the  front  of  the  arm  and 
under  the  arm  just  above  the  elbow,  returning  to  the  point 
of  origin ;  repeat  this  turn,  but,  on  reaching  the  axilla  the 
second  time,  cross  the  back  and  pass  around  the  chest,  in- 
cluding the  arm  ;  keep  on  with  these  turns,  each  alternate 
turn  going  over  the  injured  clavicle,  each  alternate  turn 
encircling  the  arm  and  the  body,  the  first  turns  advancing 
and  the  second  turns  ascending  (PL  13,  Fig.  4).  Pin  the 
crossed  pieces.  This  bandage  is  used  for  fracture  of  the 
clavicle. 

Desault's  Apparatus. — This  apparatus  consists  of  three 
rollers,  a  pad,  and  a  sling.  Each  roller  is  two  and  a  half 
inches  wide  and  seven  yards  long.  The  pad,  which  is 
wedge-shaped,  is  inserted  into  the  axilla  with  the  base  up. 
T\\^  first  roller  is  used  to  hold  the  pad  (PL  13,  Fig.  l).  The 
second  roller  binds  the  arm  to  the  side  over  the  pad.  This 
pad  is  a  fulcrum,  the  shoulder  is  the  weight,  the  arm  is  the 
lever,  and  the  second  roller  of  Desault  corrects  the  inward 
deformity  of  a  fractured  clavicle  (PL  13,  Fig.  2).  The  third 
roller  corrects  the  downward  and  forward  displacement.  It 
starts  in  the  axilla  of  the  sound  side  anteriorly,  crosses  the 
chest  to  the  shoulder  of  the  injured  side,  runs  down  the 
back  of  the  arm,  around  the  elbow,  and  crosses  the  chest 
to  the  point  of  origin,  forming  the  anterior  triangle ;  it  is 
now  carried  through  the  axilla  of  the  sound  side  to  the 
back,  crosses  the  back  to  the  shoulder  of  the  injured  side, 
runs  down  the  front  of  the  arm,  around  the  elbow,  and 
across  the  back  to  the  axilla  of  the  sound  side,  forming  the 
posterior  triangle  (PL  13,  Fig.  3).  The  formula  for  the 
Desault  bandage  is  :  Start  in  the  axilla  of  the  sound  side 
anteriorly,  run  from  the  axilla  to  the  shoulder,  from  the 
shoulder  to  the  elbow,  from  the  elbow  to  the  axilla,  and 
pass  to  the  back ;  from  the  axilla  to  the  shoulder,  from  the 
shoulder  to  the  elbow,  from  the  elbow  to  the  axilla,  and  pass 


692  A   MANUAL    OF  SURGERY. 

to  the  front.     Pin  the  crossed  pieces  and  hang  the  hand  in  a 
sling  (PL  13,  Fig.  3). 

Recurrent  Bandag-e  of  the  Head. — Take  a  roller  two 
inches  wide  and  six  yards  long.  Make  two  circular  turns 
horizontally  around  the  forehead  and  head  ;  when  the  middle 
of  the  forehead  is  reached,  catch  the  bandage,  take  a  half 
turn,  carry  the  bandage  to  the  occiput,  let  an  assistant  catch 
it,  take  a  half  turn,  bring  the  roller  forward  to  the  forehead, 
covering  a  portion  of  the  preceding  turn ;  continue  this  pro- 
cess until  the  scalp  is  well  covered ;  terminate  with  two  cir- 
cular turns  around  the  forehead  and  head  (PI.  10,  Fig.  3).  It 
is  often  advisable  to  take  a  turn  around  the  head  and  chin. 
Pin  the  crossed  pieces. 

Recurrent  Bandage  of  a  Stump. — Take  a  roller  two 
inches  wide  and  six  yards  long.  Make  two  light  circular 
turns  around  the  root  of  the  stump ;  make  recurrent  turns 
covering  the  stump  as  is  done  in  covering  the  head ;  take  a 
circular  turn  around  the  root  of  the  stump,  oblique  turns  to 
the  top  of  the  stump,  circular  turns  around  the  tip,  and  apply 
an  ascending  spiral  reversed  bandage  (PL  1 1,  Fig.  5). 

T-Bandage  of  the  Perineum. — Pass  the  transverse  part 
around  the  body  above  the  iliac  crests,  and  pin  it  in 
front;  bring  one  of  the  tails  over  the  dressing  and  up 
between  the  thigh  and  the  genitals  of  one  side,  and  the 
other  tail  over  the  dressing  and  up  between  the  thigh  and 
the  genitals  of  the  opposite  side ;  secure  these  tails  to  the 
horizontal  band. 

Handkerchief  Bandages. — Take  unbleached  muslin  one 
yard  square.  The  muslin  folded  once  makes  an  oblong 
bandage ;  bringing  its  diagonal  angles  together  makes  a 
triangle  bandage ;  a  cravat  is  formed  by  folding  a  triangle 
bandage  from  summit  to  base ;  a  cord  is  a  twisted  cravat. 
The  triangle  makes  an  admirable  sling. 

Fixed  Dressings  :  Plaster- of-Paris  Bandage. — Cover  the 


BANDAGING. 


Plate  13. 


1-3.   Desaulfs   Bandage:    i,   First  Roller;   2,  Second   Roller;  3,   Third   Roller;   4,  Velpeau's 
Bandage;  5,  Figure-of-8  Bandage  of  the  Breast;  6,  Spica  of  the  Shoulder. 


PLASTIC  SURGERY.  693 

extremity  with  a  cotton  or  flannel  bandage  or  with  a  woollen 
stocking.  Take  a  gauze  roller  infiltrated  with  plaster,  and 
place  it  endwise  in  a  basin  of  cold  water,  the  water  covering 
the  plaster.  When  bubbles  cease  to  come  off,  squeeze  the 
bandage  and  apply  it  without  miicJi  tension^  smoothing  out 
each  turn  with  a  moistened  hand.  As  each  bandage  is 
taken  from  the  basin,  drop  a  fresh  one  into  the  water. 
Apply  four  thicknesses  of  bandage,  and  finish  the  dressing 
by  sprinkling  dry  plaster  over  the  bandage  and  smoothing  it 
with  wet  hands.  The  ordinary  plaster  will  set  in  from  fifteen 
to  thirty  minutes.  If  it  is  desired  to  have  it  set  more  rapidly, 
put  salt  or  alum  in  the  water;  if  to  have  it  set  more  slowly, 
pour  stale  beer  into  the  water.  The  plaster  bandage  is  re- 
moved by  sawing  it  down  the  front  or  by  moistening  with 
dilute  hydrochloric  acid  and  then  cutting  through  the  moist- 
ened line  with  a  strong  knife. 

Silicate-of-soda  Dressing. — Protect  the  part  as  is  done 
for  a  plaster  bandage.  Bandage  the  limb  loosely  with  an 
ordinary  muslin  bandage,  paint  this  bandage  with  silicate  of 
soda,  apply  another  bandage  and  paint  it,  and  so  on  until 
six  layers  are  applied.  Gauze  bandages  soaked  in  silicate 
are  better  than  ordinary  bandages.  Silicate  dressings  require 
from  twelve  to  eighteen  hours  to  dry,  and  they  are  removed 
by  softening  with  water  and  cutting. 


XXXIII.   PLASTIC  SURGERY. 

Plastic  surgery  includes  operations  for  the  repair  of  de- 
ficiencies, for  the  replacement  of  lost  parts,  for  the  restora- 
tion of  functions  in  parts  tied  down  by  scars,  and  for  the  cor- 
rection of  disfiguring  projections.  The  following  are  the 
methods  used :  ^ 

Displacement  is  the  method  of  stretching  or  of  sliding: 

^  American  Text- Book  of  Surgery. 


694  ^   MANUAL    OF  SURGERY. 

(i)  approximation  after  freshening  the  edges  (as  in  hare- 
hp;  (2)  sHding  into  position  after  transferring  tension  to 
other  locaHties  (linear  incisions  to  allow  of  stretching  of 
the  skin  after  large  wounds).  Interpolation  is  the  method 
of  borrowing  material  from  an  adjacent  or  a  distant  region 
or  from  another  person:  (i)  ti'ansferring  a  flap  with  a 
pedicle,  which  flap  is  put  in  place  at  once  or  is  gradually 
gotten  into  place  by  a  series  of  partial  operations ;  (2)  trans- 
planting zvithont  a  pedicle,  which  is  performed  by  placing 
in  position  and  by  fixing  there  portions  of  tissue  recently 
removed  from  the  part,  from  another  part  of  the  same  indi- 
vidual, or  from  a  lower  animal  (as  the  button  of  bone  after  tre- 
phining, or  in  nerve-grafting),  or  by  skin-grafting.  Retrench- 
ment is  the  removal  of  redundant  material  and  the  produc- 
tion of  cicatricial  contraction. 

Skin-grafting-. — In  Reverdiji's  method  the  surface  to  be 
grafted  should  possess  healthy  granulations  which  are  at  the 
skin  level.  The  grafts  may  come  from  the  person  to  be 
grafted  or  from  another  person.  Cleanse  the  skin  from 
which  the  grafts  are  to  come,  the  ulcer,  and  the  skin  about 
it,  and,  if  corrosive  sublimate  is  used,  wash  it  away  with 
a  stream  of  warm  normal  salt-solution.  Thrust  a  sewing- 
needle  under  the  epidermis  to  lift  it  up,  cut  off  the  graft 
with  a  pair  of  scissors,  and  place  the  cut  surface  of  the  graft 
upon  the  ulcer.  After  applying  a  number  of  grafts  place 
thin  pieces  of  gutta-percha  tissue  over  the  grafts  and  extend- 
ing on  each  side  of  the  ulcer,  and  so  placed  as  to  allow 
drainage.  This  tissue,  after  being  asepticized,  is  moistened 
with  warm  normal  salt-solution  (^  of  i  per  cent.).  Dress 
with  a  pad  of  aseptic  gauze  moistened  with  salt-solution ; 
place  over  this  gauze  a  rubber  dam,  and  over  the  latter 
absorbent  cotton  and  a  bandage.  In  the  case  of  children 
apply  a  light  silicate  bandage.  Put  the  patient  in  bed.  In 
forty-eight  hours  remove  all  the  dressings  except  the  gutta- 


PLASTIC  SURGERY.  695 

percha  tissue,  irrigate  with  normal  salt-solution,  and  reapply 
the  dressings.  All  signs  of  the  grafts  will  often  have  disap- 
peared. In  a  day  or  two,  at  the  site  of  grafting,  bluish- 
white  spots  should  appear,  which  are  islands  of  epidermis. 
Each  graft  is  capable  of  forming  about  half  an  inch  of 
cicatrix.  Grafting  stimulates  the  edges  of  the  ulcer  to 
cicatrize  and  contract.  The  spot  from  which  the  grafts 
are  taken  is  dressed  antiseptically.  Reverdin's  method  does 
not  limit  cicatricial  contraction  to  any  great  degree,  and  the 
new  skin  is  apt  to  break  down.  At  the  end  of  seven  days 
the  special  dressings  can  be  dispensed  with. 

TJiiersclis  MetJiod. — Thoroughly  asepticize  the  ulcer,  the 
surrounding  skin,  and  the  site  from  which  the  graft  is  to 
come  (the  inner  side  of  the  arm  or  the  thigh),  and  wash 
away  the  mercurial  preparation  with  normal  salt-solution. 
Apply  dressings  wet  with  salt-solution.  On  bringing  the 
patient  into  the  operating-room,  remove  the  dressings  from 
the  ulcer,  scrape  the  ulcer  and  its  edges,  irrigate  with  salt- 
solution,  and  compress  to  arrest  hemorrhage.  Grafts  are  then 
obtained  by  putting  the  prepared  skin  upon  the  stretch  and 
cutting  strips  with  a  razor.  While  the  razor  is  being  used 
the  part  is  constantly  irrigated  with  salt-solution.  The 
grafts  are  pressed  into  place,  and  each  graft  overlaps  a  little 
the  edges  of  the  wound  and  the  adjacent  grafts.  Mixter's 
apparatus  enables  one  to  perform  this  operation  with  great 
neatness  and  speed.  The  skin-wound  is  dressed  antisep- 
tically, and  the  grafted  area  is  dressed  as  in  Reverdin's 
method.  Recently  it  has  been  suggested  that  a  ring  of 
aseptic  gauze  be  made  to  encircle  the  limb  below  the  grafted 
area,  and  another  ring  above  the  grafted  area ;  on  these  pads 
little  strips  of  wood  wrapped  in  aseptic  gauze  are  so  laid  as 
to  make  a  cage,  and  around  this  cage  the  dressings  are 
applied  (moist  chamber  plan). 


696  A   MANUAL    OF  SURGERY. 

XXXIV.    DISEASES  AND    INJURIES   OF   THE 
GENITO-URINARY   ORGANS. 

Haematuria. — By  this  term  is  meant  the  voiding  of  bloody 
urine  or  pure  blood,  the  blood  arising  from  any  portion  of 
the  urinary  apparatus,  and  the  condition  being  a  symptom, 
and  not  a  disease.  Haematuria  may  be  a  symptom  of  disease 
or  of  injury  of  some  part  of  the  urinary  system,  of  blood-dis- 
organizations (purpura,  scurvy,  or  variola),  or  of  metallic 
poisoning  (mercury,  lead,  or  arsenic).  The  color  of  the 
urine  in  haematuria  may  be  anything  between  a  light-red 
and  a  decided  black,  but  these  colors  may  be  produced  by 
agents  other  than  blood.  Senna  and  rhubarb  make  urine 
red ;  carbolic  and  salicylic  acids,  brown ;  beet-root  and 
sorrel,  the  color  of  blood.  In  jaundice,  melanosis,  and 
splenic  fever  the  urine  becomes  brown.  Be  sure  that  bloody 
urine  in  the  female  is  not  due  to  admixture  with  menstrual 
blood. 

Tests  for  Blood. — Spectroscope  Test. — Fresh  urine  diluted 
with  water  shows  the  two  absorption  bands  of  oxyhaemo- 
globin.  The  addition  of  ammonium  sulphide  causes  the  two 
bands  to  give  place  to  the  band  of  reduced  haemoglobin.  If 
bloody  urine  stands  for  some  time  the  four  bands  of  methaemo- 
globin  are  discovered  (Von  Jaksch). 

Heller's  Test. — Add  to  the  urine  potassium  hydrate,  and 
boil :  a  red  precipitate  of  earthy  phosphates  and  haematin 
forms.  Throw  the  precipitate  upon  a  filter  and  treat  with 
acetic  acid  :  a  red  solution  is  produced,  which  soon  fades. 

RoserithaV s  Test. — Take  the  precipitate  from  caustic  pot- 
ash, dry  it,  and  test  it  for  haematin  ;  put  some  of  the  dry 
sediment  on  a  slide,  add  a  crystal  of  common  salt,  apply 
a  cover-glass,  and  cause  a  few  drops  of  glacial  acetic  acid 
to  flow  under  the  glass;  warm,  but  do  not  boil.  Teich- 
mann's  crystals  will  appear  on  cooling. 


DISEASES   OF  THE    GENI TO- URINARY  ORGANS.      697 

Struves  Test. — Test  the  urine  with  hydrate  of  potassium, 
and  add  acetic  acid  in  excess  :  a  dark  precipitate  forms,  which 
will  yield  crystals  of  hsematin  when  treated  with  sal  ammo- 
niac, and  glacial  acetic  acid. 

Alniejis  Test. — Take  10  cc.  of  urine,  and  pour  upon  its 
surface  a  mixture  of  equal  parts  of  tincture  of  guaiac  and 
old  oil  of  turpentine:  at  the  point  of  junction  of  this  fluid 
with  the  urine  there  forms  a  white  ring  which  turns  blue. 

Microscope  Test. — The  microscope  shows  numerous  cor- 
puscles except  in  a  very  alkaline  urine,  when  but  few  cor- 
puscles may  be  found. 

In  haemoglobinuria — a  condition  sometimes  occurring  in 
burns,  acute  maladies,  and  metallic  poisoning — there  is  pres- 
ent blood  coloring  matter,  which  is  shown  by  Heller's  test 
and  by  Almen's  test.  The  spectroscope  shows  methaemo- 
globin.  The  microscope  shows  no  corpuscles  or  only  a  few, 
but  discloses  masses  of  pigment. 

Bleeding  from  the  Kidney-substance. — Bleeding  from  the 
pelvis  of  the  kidney  and  from  the  iweter  may  be  due  to  inflam- 
mation, congestion,  contusion,  stone,  vicarious  menstruation, 
hemorrhagic  diathesis,  powerful  diuretics,  fevers,  purpura, 
tumors,  catheterization  of  the  bladder,  etc.  Blood  is  thor- 
oughly mixed  with  the  urine,  and  no  sediment  forms  (smoky 
urine).  The  corpuscles  are  profoundly  altered,  are  devoid 
of  coloring  matter,  and  show  pale-yellow  rings.  The  severity 
of  the  hemorrhage  is  measured  by  the  number  of  the  cor- 
puscles. Von  Jaksch  states  that  the  diagnosis  between  renal 
and  ureteral  hemorrhage  rests  on  the  nature  of  the  casts 
and  the  epithelium  present.  From  the  pelvis  of  the  kidney 
and  from  the  ureter  comes  small  epithelium,  the  cells  from 
the  superficial  layers  being  polygonal  or  elliptical,  those  from 
the  deeper  layers  being  oval  or  irregular.  In  hemorrhage 
from  the  ureter  the  cells  are  few ;  in  hemorrhage  from  the 
pelvis  they  are  plentiful    and  rest   upon    one    another    like 


698  A   MANUAL    OF  SURGERY. 

"tiles  on  a  roof"  (Von  Jaksch).  Cells  from  the  tubules  of 
the  kidney  are  small,  granular,  and  polyhedral,  have  large 
nuclei,  and  are  often  so  arranged  as  to  form  cylinders 
(epithelial  casts).  The  urine  of  renal  hemorrhage  is  apt  to 
be  acid  unless  alkalies  have  been  administered,  unless  the 
bleeding  has  been  severe,  or  unless  pus  is  present  in  the 
urine.  A  very  large  renal  hemorrhage  may  cause  the 
passage  of  almost  pure  blood.  In  renal  haematuria  there 
are  aching  in  the  loin,  numbness  of  the  corresponding  leg, 
and  often  renal  colic. 

Vesical  hemorrhage,  including  hemorrhage  from  the 
prostate,  may  follow  the  relief  of  retention  of  urine,  may  be 
due  to  stone,  inflammation,  tumor,  etc.,  or  may  arise  from 
traumatisms,  instrumental  or  otherwise.  The  color  of  the 
urine  is  usually  bright-red,  but  if  long  retained  in  the  blad- 
der it  becomes  black  and  often  tarry.  The  reaction  is  alka- 
line. The  clots,  when  floated  out,  are  large  and  without 
definite  shape.  In  micturition  the  urine  is  clear  or  onl}^  a 
little  colored  at  the  beginning,  but  becomes  darker  and  darker 
as  micturition  ends,  at  which  time  the  flow  may  consist  of 
almost  pure  blood.  In  very  small  vesical  hemorrhages  the 
urine  may  be  smoky.  Crystals  of  triple  phosphate  indicate 
bladder  disorder.  The  microscope  shows  colorless  and 
swollen  corpuscles  and  many  polygonal  cells.  Symptoms 
of  bladder  mischief  usually  exist,  but  cystoscopic  examina- 
tions or  exploratory  suprapubic  cystotomy  may  be  demanded 
for  the  diagnosis. 

Urethral  Hemorrhage. — In  urethral  bleeding  blood  comes 
independently  of  micturition,  or  blood  comes  out  first  and 
is  followed  by  pure  water.  Urethral  hemorrhage  arises  from 
an  acute  urethritis,  from  an  inflamed  stricture,  from  the  pas- 
sage of  an  instrument,  or  from  some  other  traumatism. 

Pain  in  Genito -urinary  Diseases. — Pain  as  a  symptom 
of  genito-urinary  disease  may  be  found  at  some  point  dis- 


DISEASES   OF   THE    GENITO- URINARY  ORGANS.      699 

tant  from  the  seat  of  lesion.  A  stone  in  the  bladder  causes 
pain  in  the  head  of  the  penis  just  back  of  the  meatus  ;  stone  in 
the  kidney  induces  pain  in  the  loin,  the  groin,  the  thigh,  and 
the  testicle ;  inflammation  of  the  testicle  causes  pain  in  the 
line  of  the  cord  in  the  groin.  In  other  cases  of  genito-urinary 
disease  pain  is  felt  at  the  seat  of  lesion,  as  in  urethritis  and 
prostatitis.  Pain  felt  before  micturition,  and  being  relieved 
by  the  act,  is  found  in  cystitis  and  in  retention  of  urine. 
Pain  is  felt  during  micturition  in  inflammation  of  the  bladder, 
prostate,  and  urethra  and  in  the  passage  of  gravel  or  stone. 
Pain  which  is  acute  at  the  end  of  micturition  is  noted  in 
stone  in  the  bladder,  in  inflammation  of  the  neck  of  the 
bladder,  and  in  inflammation  of  the  prostate  gland.  The 
pain  of  stone  in  the  bladder,  it  may  be  observed,  is  amelior- 
ated by  rest  and  is  aggravated  by  exercise.  The  pain  of 
acute  prostatitis  is  intensified  by  defecation. 

Frequency  of  Micturition. — Frequent  micturition  arises 
from  irritation  of  the  sensory  nerves,  from  phimosis,  con- 
tracted meatus,  inflammations,  very  acid  urine,  calculi,  ure- 
thral stricture,  and  hyperaesthesia  of  the  urethra.  Frequency 
of  micturition  may  be  due  to  spinal  irritability  from  concus- 
sion or  from  sexual  excess,  from  contraction  of  the  bladder 
rendering  the  viscus  unable  to  hold  much,  or  from  excessive 
urinary  secretion,  as  in  diabetes  or  in  the  first  stage  of  con- 
tracted kidney.  Frequent  micturition  exists  in  obstruction 
by  enlarged  prostate  and  in  atony  of  the  bladder-walls. 
Hypersecretion  of  urine  plus  bladder  intolerance  is  known 
as  "  nervousness,"  and  is  found  in  hysteria.  Frequency  of 
micturition  increased  by  movement  is  observed  in  stone 
and  tumor  of  the  bladder ;  increased  by  rest,  is  found  in 
enlarged  prostate  and  atony  of  the  muscular  walls  of  the 
viscus.  Frequency  of  micturition  with  diminution  of  stream- 
calibre  suggests  a  constriction  of  the  urethral  diameter ;  fre- 
quency of  micturition  with  diminished  force  suggests  a  pos- 


700  A   MANUAL    OF  SURGERY. 

tcrior  stricture,  enlarged  prostate,  or  bladder  atony.  Slow- 
ness of  micturition  hints  at  enlarged  prostate,  atony,  or 
urethral  stricture. 

Tlionipson  s  diagnostic  questions  are  as  follows  : 

"  I.  Have  you  any,  and,  if  so,  what,  frequency  in  passing 
water?  Is  frequency  more  manifest  during  the  night  or  the 
day  ?  Is  frequency  more  manifest  during  motion  or  rest  ? 
Does  any  other  circumstance  affect  it? 

"  2.  Is  there  pain  on  passing  urine,  and,  if  so,  is  it  before, 
during,  or  after  the  act?  What  is  its  character — acute, 
smarting,  dull,  transitory,  or  continuous  ?  What  is  its  seat  ? 
Is  it  felt  at  other  times,  and  is  it  produced  or  intensified  by 
sudden  movements  ? 

"  3.  What  is  the  character  of  the  stream  ?  Is  it  small  or 
large;  twisted  or  irregular;  strong  or  weak;  continuous,  re- 
mitting, or  intermitting  ?  Does  it  come  by  the  meatus,  or 
partly  or  entirely  through  fistulae  ? 

**  4.  Is  the  character  of  the  urine  altered  ?  What  is  its 
appearance,  color,  odor,  reaction,  and  specific  gravity  ?  Is 
it  clear  or  turbid,  and  if  turbid,  is  it  so  at  the  time  of  pass- 
ing ?  Does  it  vary  in  quantity  ?  Are  the  normal  constitu- 
ents increased  or  diminished  ?  Does  it  contain  abnormal 
elements,  as  albumin  or  sugar  ?  What  inorganic  deposits 
are  found  ?     What  organic  materials  are  met  with  ? 

"5,  Has  the  urine  ever  contained  blood?  If  so,  was 
the  color  brown  or  bright  red ;  were  the  blood  and  urine 
thoroughly  mixed  ;  was  the  blood  passed  at  the  end  or  at 
the  beginning  of  micturition,  or  did  it  come  only  with  the 
last  drops  of  urine ;  or  was  it  passed  independently  of 
micturition  ? 

"  6.  Inquire  as  to  pain  in  the  back,  loins,  and  hips,  perma- 
nent or  transitory,  or  for  the  occurrence  of  severe  paroxysms 
of  pain  there." 

Mobile  Kidney. — There  are  two  forms  of  this  condition  : 


DISEASES   OF   THE    GENITO-URIXARY  ORGANS.      7OI 

(i)  Movable  kidney,  a  kidney  freely  moving-  back  of  the 
peritoneum,  either  within  the  cavity  of  its  fibro-fatty  capsule 
or  entirely  without  its  capsule  (this  condition  is  acquired) ; 
and  (2)  floating  or  wandering  kidney,  a  kidney  having  a 
mesonephron  and  lying  within  the  peritoneal  cavity  (this 
rare  condition  is  always  congenital).  Keen  states  that  there 
mav  be  drawn  a  clear  theoretical  distinction  between  movable 
and  floating  kidney,  but  practically  there  is  no  rigid  line  of 
demarcation,  as  a  movable  kidney  may  have  as  large  a 
range  of  movement  as  a  floating  one.  When  a  movable 
kidney  becomes  fixed  in  an  abnormal  situation  the  organ  is 
spoken  of  as  dislocated.  The  organ  may  drop  below  the 
brim  of  the  pelvis,  may  cross  the  vertebral  column,  or  may 
reach  the  anterior  abdominal  wall.  Women  more  often 
suffer  from  movable  kidnev  than  do  men,  and  it  is  found 
in  the  great  majority  of  cases  upon  the  right  side.  Floating 
kidney  is  always  congenital.  Among  the  assigned  causes 
of  the  movable  condition  are  to  be  named  traumatisms, 
strains,  abdominal-wall  laxity  from  pregnancy,  absorption 
of  peritoneal  fat  from  wasting  disease  (Edebohls)  and  tight 
lacing. 

Symptoms  of  Both  Forms. — There  may  be  no  discomfort 
whatever,  or  the  patient  may  be  a  confirmed  invalid.  The 
usual  symptoms  are  epigastric  pain  (just  to  the  left  of  the 
middle  line)  which  disappears  when  the  kidney  is  replaced, 
dragging  pain  in  the  loin,  and  paroxysms  like  nephritic  colic. 
There  is  a  sense  of  a  moving  body  in  the  abdomen,  and  the 
patient  has  aggravated  indigestion,  often  accompanied  by 
vomiting.  Constipation  is  the  rule,  and  violent  attacks  of 
cardiac  palpitation  are  common.  Most  subjects  of  this 
kidney-mobility  are  extremely  nervous,  many  of  them  hys- 
terical or  hypochondriacal.  In  women  the  sexual  organs 
are  almost  invariably  deranged,  and  menstruation  aggravates 
the  pain  and  discomfort.     All  the  symptoms  are  intensified 


702  A   MANUAL    OF  SURGERY. 

by  exertion  and  are  modified  by  rest.  The  urine  is  normal. 
The  proof  of  the  existence  of  movable  kidney  is  the  finding 
of  a  tumor  (movable  on  respiration,  change  of  position,  and 
palpation)  shaped  like  that  organ,  pressure  upon  which  oc- 
casions no  sensation  or  causes  pain  or  a  sickening  feeling. 
A  "  lumbar  recess  "  (Morris)  may  be  found,  and  percussion 
over  the  loin  gives  resonance.  A  movable  kidney  must  not 
be  mistaken  for  a  distended  gall-bladder,  a  tumor  of  the 
mesentery,  stomach,  or  omentum,  a  phantom  tumor,  an 
ovarian  tumor,  or  a  cancer  of  the  pancreas.  Sometimes  a 
movable  kidney  endangers  life,  rupture  of  the  kidney  or 
twisting  or  rupture  of  the  ureter  occurring,  the  ultimate  cause 
of  death  being  albuminuria,  uraemia,  or  hydronephrosis. 

TreatDient. — Mobile  kidney  is  treated  as  follows:  (i)  The 
rest-trcatincnt  of  Weu'  Mitchell  may  be  tried ;  it  often  markedly 
mitigates  the  symptoms,  but  does  not  seem  to  cure.  (2) 
Bandage  and  pad  should  always  be  tried,  using  the  pad  of 
Dunninsf  or  Newman :  this  will  cure  not  a  few  cases. 
Edebohls  uses  only  a  bandage  of  elastic  webbing  or  a  well- 
fitting  corset.  (3)  Nephroj'rhaphy  is  the  proper  procedure 
in  most  instances  (p.  711).  (4)  Nephrectomy  in  rare  cases 
is  necessary ;  it  may  be  done  for  dislocated  kidney,  when 
kidney  disease  exists,  or  when  nephrorrhaphy  has  failed  in 
a  case  of  severity. 

Injuries  of  the  Kidney. — Laceration  or  rupture  is 
caused  by  falls  and  by  blows  upon  the  back  and  the  belly. 
The  blood  may  or  may  not  extravasate  into  surrounding 
structures.  The  symptoms  are — pain  in  the  loin,  shooting 
into  the  testicle  or  the  thigh  ;  frequent  and  painful  passage 
of  bloody  urine  or  suppression  of  urine ;  the  loin  is  full  and 
is  dull  on  percussion,  and  collapse  or  evidences  of  internal 
hemorrhage  exist.  Bloody  urine  is  not  proof  of  renal  injury, 
and  kidney  damage  may  occur  without  haematuria. 

Treatment. — If  the  shock  is  profound  with  increasing  ful- 


DISEASES   OF   THE    GENITO-URINARY  ORGANS.      703 

ness  of  the  loin,  whether  haematuria  exists  or  not,  or  if  blood 
comes  profusely  from  the  urethra,  make  an  exploratory- 
lumbar  incision  and,  if  necessary,  remove  the  organ.  Ordi- 
narily the  cases  are  treated  by  rest  in  bed  and  by  feeding 
with  liquid  food  or  by  nutritive  enemata  to  prevent  vomiting. 
Ergot,  opium,  or  gallic  acid  may  be  used.  Apply  ice-bags  to 
the  loin  and  the  side  of  the  abdomen,  and  after  bleeding  ceases 
strap  the  loin  and  apply  a  binder.  If  large  blood-clots  cause 
pain  or  retention,  introduce  a  catheter  and  inject  the  bladder 
with  boracic  acid,  or  use  the  tube  and  evacuator  of  a  Bigelow 
apparatus.     If  this  procedure  fails,  open  the  bladder. 

Perforating"  wounds  of  the  kidneys,  if  posterior,  do  not 
involve  the  peritoneum  ;  if  anterior,  they  do.  The  symptoms 
are — escape  of  blood  and  urine  by  the  wound;  haematuria  is 
usual,  but  not  invariable ;  pain  as  in  rupture ;  the  patient 
may  be  unable  to  micturate ;  and  nausea,  vomiting,  and  con- 
stitutional signs  of  hemorrhage  exist.  Traumatic  peritonitis, 
perinephric  abscess,  or  general  sepsis  may  ensue.  Confirm 
the  diagnosis  by  exploration  with  the  finger.  Extraperi- 
toneal injuries  give  a  good,  and  intraperitoneal  a  bad, 
prognosis. 

Treatme7it. — If  the  wound  in  perforated  kidney  is  extra- 
peritoneal, enlarge  it  to  permit  of  drainage,  and  arrest  hem- 
orrhage by  packing  and  hot  water.  Asepticize  the  wound, 
insert  a  drainage-tube  down  to  the  kidney,  dress  often  with 
bichloride  gauze,  keep  the  patient  in  bed  on  a  low  diet,  and 
give  ergot  and  opium.  In  intraperitoneal  wounds,  perform 
an  abdominal  section  and  remove  the  damaged  organ  (see 
Nephrectomy) . 

Renal  Calculus. — A  stone  in  the  kidney  is  formed  by  the 
precipitation  of  urinary  salts  into  the  renal  epithelial  cells 
and  the  gluing  together  of  these  salts  and  cells  by  material 
from  mucus  or  blood-clot,  this  mass  serving  as  a  nucleus 
on  which  accretion  takes  place.     Most  calculi  escape  when 


704  A   MANUAL    OF  SURGERY. 

small  as  gravel.  The  cause  is  a  highly  acid  urine  which 
induces  catarrh  of  the  renal  tubes.  This  high  concentration 
of  urine  is  favored  by  a  sedentary  life,  by  the  ingestion  of 
much  alcohol  or  nitrogenous  food,  by  constipation,  by  an 
inactive  skin,  and  by  a  torpid  liver.  The  children  of  poverty 
are  liable  to  calculi  because  of  the  use  of  unsuitable  foods 
and  the  formation  of  great  amounts  of  nitrogenous  waste. 
Males  more  often  suffer  than  do  females,  certain  locations 
favor  the  development  of  the  malady,  and  a  family  liability 
sometimes  exists. 

Symptoms. — The  symptoms  of  stone  in  the  kidney  may 
not  appear  for  years,  but  usually  they  are  manifested  early. 
Nephritic  colic  is  due  to  the  washing  of  a  calculus  into  the 
orifice  of  the  ureter,  which  it  blocks,  tears,  or  distends.  The 
pain  is  either  sudden  or  gradual  in  onset,  is  fearful  in  intensity, 
and  runs  from  the  lumbar  region  down  the  corresponding 
thigh  and  spermatic  cord  (the  testicle  being  retracted)  and 
into  the  abdomen  and  shoulder-blade.  There  are  nausea, 
vomiting,  collapse,  sometimes  unconsciousness  or  convul- 
sions. Frequent  attempts  at  making  water  are  productive 
of  pain,  but  of  little  urine.  The  urine  is  usually,  but  not 
always,  smoky  from  blood.  After  a  time  the  pain  vanishes, 
the  stone  having  passed  into  the  bladder  or  having  fallen 
back  into  the  pelvis  of  the  kidney.  A  calculus  retained  in  the 
kidney  eventually  excites  pyelitis.  There  is  pus  in  the  urine, 
and  soreness  or  pain  in  the  loin  exists.  Attacks  of  colic 
occur  from  the  passage  of  small  stones  or  of  plugs  of 
mucus.  Entire  obstruction  of  the  ureter  induces  hydro- 
nephrosis or  pyonephrosis.  Nephrolithiasis  may  cause  death 
by  exhaustion,  by  sepsis,  by  rupture  of  a  hydronephrosis,  or 
by  amyloid  degeneration. 

Treatment. — In  the  gravel  of  uric-acid  diathesis,  use 
alkalies,  especially  the  liquor  potassii  citratis,  and  reduce 
the  amount  of  nitrogen  in  the  diet  to  a  minimum,  at  the 


DISEASES   OF   THE    GENITO- URINARY  ORGANS.      705 

same  time  washing  out  the  organs  by  copious  draughts 
of  Poland  water  or  Londonderry  hthia.  Piperazine.  in  doses 
of  grs.  V  to  grs.  viij  three  times  a  day,  is  highly  commended. 
Exercise  is  to  be  insisted  on.  When  gravel  is  phosphatic, 
order  strychnine,  the  mineral  acids,  and  rest  at  the  sea- 
side. When  oxalate  of  lime  is  found,  restrict  diet,  use  the 
mineral  acids,  recommend  travel  or  rest  amid  new  sur- 
roundings, and  give  an  occasional  course  of  sodii  phos- 
phas,  -,5ss  three  times  a  day,  drunk  in  Buffalo  lithia  water. 
Nephritic  colic  is  relieved  by  hypodermatic  injection  of 
morphia  and  atropia,  the  hot  bath,  diluent  drinks,  or  the 
inhalation  of  ether.  After  the  attack  wash  out  the  bladder 
with  an  evacuator.  If  a  stone  impacts  in  the  ureter,  perform 
the  operation  of  ureterolithotomy.  The  diagnosis  of  this 
impaction  is  often  possible  only  by  exploratory  laparotomy. 
If  the  symptoms  point  to  stone  in  the  kidney,  medical  treat- 
ment having  been  used  without  avail,  and  there  being  no  evi- 
dence of  organic  disease  of  the  other  kidney,  make  an  ex- 
ploratory lumbar  incision  ;  feel  the  surface  of  the  kidney 
with  the  finger,  sound  the  inside  of  the  organ  with  a  needle, 
and  if  a  stone  is  detected  remove  it  (see  Nephrolithotomy , 
p.  709).  Dr.  Keen  is  of  the  opinion  that  operation  should 
not  be  performed  if  the  urea  is  below  I  per  cent.  If,  after 
nephrolithotomy,  suppression  of  urine  occurs,  cut  into  the 
other  kidney,  as  in  half  of  all  cases  a  stone  will  be  found 
lodged  there. 

Abscess  of  the  kidney  is  caused  by  traumatism,  by  calcu- 
lus, by  stricture  of  the  urethra,  by  disease  of  the  bladder,  by 
the  union  of  miliary  abscesses,  or  by  pyaemia.  The  symptoms 
are  pus  in  the  urine  (this  is  usual,  but  not  invariable),  haema- 
turia  in  traumatic  cases,  and  pain  running  into  the  groin. 
Constitutional  symptoms  of  suppuration  exist.  The  treat- 
ment in  the  early  stage  is  rest,  morphia,  purgation,  ano- 
dynes, and  ice-bags  to  the  loin,  followed  in  forty-eight  hours 
45 


706  A   MANUAL    OF  SURGERY. 

by  hot  fomentations.  When  the  diagnosis  is  clear,  incise 
the  loin,  open  and  stitch  the  kidney  to  the  abdominal  wall, 
or,  if  the  organ  be  badly  damaged,  remove  it. 

Pyelitis  and  pyelonephritis,  which  affect  usually  only  one 
gland,  are  caused  by  urethral  stricture,  by  stopping  of  the 
ureter  by  blood-clot,  by  vesical  paralysis,  by  stone  in  the 
bladder  or  in  the  kidney,  and  by  enlargement  of  the  prostate 
gland. 

Symptoms. — A  patient  who  has,  or  who  has  had,  retention 
of  urine  develops  high  fever  often  preceded  by  a  chill ; 
headache,  stupor,  and  dry  tongue  are  noted.  Unlike  acute 
Bright's  disease,  there  is  neither  oedema  nor  dry  skin,  con- 
vulsions do  not  occur,  and  the  urine  is  plentiful  and  contains 
pus  and,  but  rarely,  blood.  The  prognosis  is  very  bad.  The 
treatment  is  to  remove  the  obstruction  if  possible.  If  the 
urine  be  acid,  give  liquor  potassii  citratis ;  if  alkaline,  give 
benzoic-acid.  Gallic  acid,  eucalyptol,  and  small  doses  of  copa- 
iba or  cubebs  are  recommended.  Quinine  is  used  to  stimulate 
the  patient  and  to  lower  fever.  The  bladder  is  to  be  washed 
out  every  day  with  boracic-acid  solution  (gr.  iij  to  5j).  Cups, 
dry  or  moist,  and  hot  sand-bags  or  bran-bags  are  to  be  applied 
to  the  loin.     Alcohol  may  be  sparingly  administered. 

Perinephritis. — The  symptoms  of  this  condition  are  rigidity 
of  the  spine,  the  inclination  being  toward  the  affected  side, 
flexion  of  the  foot,  and  often  pain  in  the  knee.  The  symp- 
toms resemble  those  of  hip-joint  disease  in  the  second  stage. 
Suppuration  may  or  may  not  take  place.  The  treatment  is 
wet  cups  to  the  loin,  ice-bags  to  the  loin,  rest,  purgation  by 
salines,  morphia  for  pain,  and,  after  the  acute  stage,  potas- 
sium iodide  internally  and  ichthyol  locally. 

Perinephric  Abscesses. — Primary  abscess  is  caused  by 
chills,  traumatism,  acute  febrile  disturbances,  or  by  pus  flow- 
ing from  some  other  part,  as  the  spine.  Consecutive  abscess 
is  secondary  to  kidney  inflammation,  suppuration,  calculus, 


DISEASES   OF   THE    GENITO-URINARY  ORGANS.      707 

tuberculosis,  or  cyst.  In  the  consecutive  form  the  symp- 
toms may  be  masked  by  the  malady  to  which  perinephric 
abscess  is  secondary.  As  a  rule,  in  perinephric  abscess 
there  are  found  the  constitutional  symptoms  of  suppuration. 
The  local  symptoms  are  a  deep  aching  and  paroxysmal  pain 
intensified  by  lumbar  pressure.  CEdema  of  the  correspond- 
ing foot  and  lameness  are  not  unusual.  CEdema  of  the  skin 
is  usual,  but  fluctuation  is  rare.  The  exploratory  incision 
will  .settle  a  doubtful  diagnosis.  The  treatment  is  to  lay 
open  the  abscess,  wash  it  out,  and  drain. 

Hydronephrosis  is  a  condition  of  the  kidney  in  which  an 
impediment  to  the  outflow  of  urine  is  caused  by  obstruction 
in  the  ureter,  the  bladder,  or  the  urethra,  the  calyces  of  the 
kidney  becoming  over-distended  with  urine  and  the  glandu- 
lar tissue  being  absorbed  by  pressure.  This  condition  may 
be  congenital,  and  is  due  usually  to  twisting  of  the  ureter  or 
to  imperforate  meatus,  both  kidneys  being  involved.  The 
causes  of  the  acquired  form  are  the  pressure  of  pelvic 
growths  or  pregnancy,  inflammation  or  tumor  of  the  blad- 
der, stone  in  the  bladder,  kidney,  or  ureter,  twisting  of  the 
ureter  of  a  movable  kidney,  enlargement  of  the  prostate 
gland,  and  stricture  of  the  urethra.  This  acquired  hydro- 
nephrosis may  involve  both  kidneys,  all  of  one  kidney,  or 
only  a  part  of  a  single  gland. 

Syniptoms  and  Treatment. — Hydronephrosis  is  most  fre- 
quent in  females.  When  tumor  is  absent  there  may  be  no 
symptoms,  or  there  may  be  pain  in  the  back  and  abdomen, 
frequent  micturition,  a  persistent  or  intermittent  diminution 
in  urine,  or  even  occasional  anuria.  A  tumor  may  be  found 
in  the  loin,  which  growth  is  dull  on  percussion  and  may 
come  and  go,  a  large  urinary  flow  being  noted  when  it  dis- 
appears. Hydronephrosis  may  last  a  long  while  if  only  one 
kidney  be  involved,  but  death  is  not  far  distant  if  both 
glands  suffer.    Death  occurs  from  ansemia,  from  pressure  on 


7o8  A   MANUAL    OF  SURGERY. 

adjacent  organs,  or  from  rupture  into  the  peritoneal  cavity. 
Treatment  by  aspiration  may  cure,  but  the  operation  may 
have  to  be  done  repeatedly.  Tapping  on  the  left  side  is 
performed  just  below  the  last  intercostal  space  ;  on  the  right 
side  the  tap  is  made  midway  between  the  last  rib  and  the 
crest  of  the  ilium.  If  repeated  aspirations  fail,  perform  a 
nephrotomy,  stitching  the  edges  of  the  cut  kidney  to  the 
surface  and  irrigating.  If  a  permanent  suppurating  fistula 
ensues  or  if  the  organ  is  found  extensively  damaged,  neph- 
rectomy is  to  be  performed,  provided  the  other  kidney  is 
in  reasonably  good  condition. 

Pyonephrosis,  or  surg-ical  kidney,  is  a  condition  in  which 
the  pelvis  and  the  calyces  of  the  kidney  are  distended  with 
pus  or  with  pus  and  urine.  The  whole  kidney  may  be  de- 
stroyed. This  condition  has  the  same  causes  as  has  hydro- 
nephrosis, for  it  is  in  reality  usually  an  infected  hydrone- 
phrosis. In  some  cases  the  inaugural  malady  is  pyelitis 
which  causes  blocking  of  a  ureter. 

Symptoms  and  Treatment. — At  first  the  symptoms  are 
those  due  to  the  obstructing  cause,  plus  pyelitis.  Pus  may 
appear  in  the  urine  in  incomplete  obstruction,  or  it  may  in- 
termittently come  and  go.  Constitutional  symptoms  of  sup- 
puration are  soon  manifest.  A  tumor  may  appear  in  the 
loin,  like  the  tumor  of  hydronephrosis.  If  only  one  kidney 
be  involved,  and  if  the  disease  is  due  to  blocking  of  a  ureter, 
recovery  is  to  be  expected.  The  treatment  in  the  early 
stages  comprises  removal,  if  possible,  of  the  cause  of  ob- 
struction and  the  employment  of  measures  directed  to  the 
cure  of  the  pyelitis.  If  obstruction  is  not  complete,  pallia- 
tive measures  may  be  employed  for  the  tumor.  If  fever  is 
continued,  if  there  is  great  visceral  derangement,  if  pain  is 
severe  and  constant,  and  if  the  tumor  continually  grows, 
perform  a  nephrotomy,  stitching  the  organ  to  the  surface  if 
possible,  or  removing  it  if  it  is  hopelessly  disorganized. 


DISEASES   OF  THE    GEyiTO-URINARY  ORGANS.      yog 

Operations  on  the  Kidney. — Nephrotomy  means  incision 
of  a  kidney,  but  the  term  is  also  applied  to  the  exploratory 
exposure  of  the  kidney  without  incision.  The  instnnnejits 
required  are  scalpels,  a  blunt-pointed  bistoury,  dissecting- 
forceps,  toothed  -forceps,  a  grooved  director,  haemostatic 
forceps,  spatula,^  metal  retractors,  a  fountain  syringe,  an 
Allis  dissector,  Hagedorn  needles,  and  an  Abbe  needle- 
holder.  If  looking  for  a  stone,  have  a  large  hare-lip  pin  to 
sound  with,  forceps  and  a  scoop  to  remove  the  stone,  and 
a  periosteum-elevator  to  scrape  away  adherent  calculi.  The 
patient  lies  upon  the  sound  side,  a  sand  pillow  being  placed 
under  the  loin.  The  incision  is  made  half  an  inch  below  the 
last  rib  and  close  to  the  outer  border  of  the  erector  spinae 
mass,  and  runs  obliquely  downward  and  forward  toward  the 
iliac  crest  for  three  inches,  the  incision  being  enlarged  later  if 
required.  Divide  the  skin,  the  superficial  fascia,  the  fat,  the 
external  oblique,  the  posterior  border  of  the  external  oblique, 
and  the  outer  edge  of  the  latissimus  dorsi.  This  incision  ex- 
poses the  lumbar  fascia.  Push  aside  the  last  dorsal  nerve 
and  incise  the  lumbar  fascia,  when  the  perirenal  fat  will  bulge 
into  the  wound.  Two  distinct  layers  of  fat  exist.  Tear  this 
fat  through  wnth  dissecting-forceps  or  with  an  Allis  dissector 
to  expose  the  kidney,  which  can  now  be  opened  while  it  is 
forced  into  the  wound  bv  the  hand  of  an  assistant  making 
abdominal  pressure. 

Nephrolithotomy. — In  this  operation  the  incision  is  the 
same  as  in  nephrotomy.  Feel  the  kidney  for  a  stone,  or,  if 
this  procedure  fails,  explore  with  a  needle  or  a  pin.  Morris 
suggests  that  first  the  organ  be  well  drawn  out.  If  no 
stone  be  found,  open  the  pelvis  and  explore  with  the  finger. 
If  a  stone  be  detected,  open  the  kidney-tissue,  loosen  the 
calculus  with  the  nail,  and  remove  it  with  the  finger,  with  a 
scoop,  or  with  forceps.  After  removing  the  stone,  stop  renal 
hemorrhage  by  pressure  and  hot  water,  or  in  some  cases 


710  A   MANUAL    OF  SURGERY. 

plug  with  iodoform  gauze  for  twenty-four  hours.  When 
hemorrhage  ceases  put  a  large  drainage-tube  down  to  the 
kidney.  Close  the  wound  in  the  muscles  and  integument, 
and  dress  antiseptically.  The  dressings  must  be  changed 
frequently  and   the  tube  should  be  shortened  daily. 

Nephrectomy  is  the  removal  of  a  kidney.  The  mortality 
for  cancer  is  lo  per  cent.,  for  tubercle  36  per  cent.  There 
are  two  methods  of  nephrectomy,  the  lumbar  and  the  ab- 
dominal. 

Lumbar  Nephrectomy. — The  instruments  required  for 
this  operation  are  scalpels,  a  blunt-pointed  bistoury,  forceps 
as  used  in  the  preceding  operation,  a  clamp,  retractors, 
spatulae,  blunt  hooks,  an  aneurysm-needle,  a  pedicle-needle, 
a  grooved  director,  stout  ^  silk,  an  Allis  dissector,  sharp 
spoons,  and  a  Pacquelin  cautery.  The  position  of  the 
patient  and  the  incision  are  the  same  as  those  for  the  pre- 
ceding operation.  When  the  kidney  is  exposed  the  incision, 
if  necessary,  may  be  enlarged  in  its  existing  directions,  or,  as 
Morris  advises,  it  may  be  enlarged  by  cutting  with  a  blunt 
bistoury  a  vertical  incision  from  a  point  one  inch  in  front  of 
the  posterior  extremity  of  the  first  cut  downward  and  from 
within  outward.  Lift  the  kidney,  and  separate  it,  if  possible, 
with  the  finger  ;  clamp  the  pedicle  ;  pass  an  armed  aneurysm- 
needle  between  the  vessels  of  the  pedicle ;  ligate  in  two  places ; 
cut  between  the  threads ;  and  arrest  hemorrhage  by  ligature 
or  by  the  cautery.  If  the  ureter  be  healthy,  drop  it  back ; 
if  it  be  foul  and  purulent,  .scrape  it  with  a  spoon,  wash  it 
with  corrosive  sublimate,  and  touch  it  with  pure  carbolic 
acid,  and  then  either- drop  it  back  or  sew  it  into  the  wound. 
If  hemorrhage  persists  from  the  wound,  plug.  Put  in  a 
drainage-tube  and  close  the  wound.  If  the  peritoneum  be 
accidentally  opened,  close  it  with  Lembert's  suture. 

Abdominal  nephrectomy  is  more  dangerous  than  the 
lumbar  operation.     The  same  instruments  are  required  as 


DISEASES   OF   THE    GEKITO-URhXARY  ORGAXS.      71I 

are  used  in  the  preceding  operation.  The  position  is  supine. 
The  incision  is  that  of  Langenbeck — four  inches  long  in  the 
Hnea  semilunaris,  its  centre  corresponding  to  the  umbilicus. 
Open  the  abdomen,  introduce  a  hand,  feel  the  kidneys,  and 
if  both  show  serious  disease  do  not  perform  nephrectomy. 
Keep  the  small  intestines  away  by  sponges,  push  the  colon 
toward  the  umbilicus,  incise  the  outer  layer  of  the  meso- 
colon, and  bare  the  kidney.  Strip  off  the  peritoneum  from 
the  kidney  and  its  vessels,  and  ligate  the  vessels  by  pass- 
ing strong  silk  through  the  centre  of  the  pedicle  with  an 
aneurysm-needle.  Ligate  the  ureter  if  healthy,  and  cut.  If 
the  ureter  is  septic,  fasten  it  to  an  opening  made  in  the  loin 
by  cutting  on  to  forceps  pushed  to  the  outer  edge  of  the 
quadratus  lumborum.  Stop  bleeding,  irrigate  the  belly- 
cavity,  and  dress  as  usual,  employing  drainage  only  when 
septic  matter  has  gotten  into  the  peritoneal  cavity  or  when 
oozing  is  persistent, 

Nephrorrhaphy  is  fixation  of  a  mobile  kidney.  The  kid- 
ney is  exposed  in  the  loin  as  above  detailed,  and  is  forced 
into  the  wound  by  abdominal  pressure.  Insert  sutures  of 
chromicized  gut,  kangaroo  tendon,  or  silkworm  gut,  by 
means  of  curved  Hagedorn  needles,  through  the  renal  sub- 
stance, and  thus  fix  the  organ  to  the  lumbar  fascia.  Use 
drainage-tubes  until  inflammation  appears.  The  mortality  is 
about  3  per  cent. 

Retention  of  Urine. — By  this  term  is  meant  an  inability 
to  empty  the  bladder.  The  retention  may  be  complete,  not 
a  drop  emerging,  or  it  may  have  been  complete,  a  dribbling 
setting  in  after  a  time,  due  to  paralysis  of  the  bladder,  which 
cannot  contain  more  fluid,  expulsion  of  the  overflow  from  the 
ureters  being  produced  by  atmospheric  pressure.  This  con- 
dition is  known  as  tlie  engorgement,  the  overfloiv,  or  tJie  in- 
continence of  retention.  There  may  be  a  partial  xqX.^Vl\ao\\ 
from  enlarged  prostate,  a  portion  only  of  the  urine  being 


712  A   MANUAL    OF  SURGERY. 

voided.  Retention  may  be  caused  by — (i)  obstruction,  result- 
ing from  urethral  stricture,  enlarged  prostate,  inflamed  pros- 
tate, occluded  meatus,  impacted  calculus,  urethral  tumors, 
complete  phimosis,  fecal  impaction,  and  pressure  from  gravid 
tumors,  or  by  (2)  defective  expulsion,  resulting  from  paralysis, 
disease  or  injury,  atony,  reflex  inhibition,  shock,  muscular 
weakness  of  fevers,  and  the  action  of  drugs  such  as  bella- 
donna, opium,  or  cantharides. 

Syniptonis. — In  acute  retention  there  is  an  agony  of  desire 
to  urinate,  the  patient  making  acutely  painful  straining  efforts 
during  which  feces  are  often  passed.  There  are  severe  pain 
and  aching  in  the  abdomen,  thighs,  perineum,  and  penis. 
All  the  symptoms  rapidly  increase,  a  typhoid  state  is  inaug- 
urated, and  death  closes  the  drama  unless  relief  be  given. 
If  retention  is  from  time  to  time  alleviated  by  the  passage 
of  a  little  water,  the  symptoms  are  slower  in  evolution  and 
are  less  intense,  and  the  case  is  said  to  be  chronic.  Some 
cases  of  gradual  onset,  due  to  atony,  are  very  insidious,  the 
patient  feeling  no  particular  pain,  and  complaining  only  of 
the  dribbling,  which  is  really  the  overflow  of  retention,  and 
is  not  a  sign  that  the  bladder  is  successfully  emptying  itself. 
In  any  case  of  retention  the  bladder  rises  above  the  pubes, 
and  there  is  found  a  pyriform,  elastic,  fluctuating  tumor  (dull 
on  percussion)  in  the  hypogastrium,  which  tumor  enlarges 
until  the  bladder  is  evacuated  or  incontinence  sets  in.  The 
flanks  of  the  patient  give  a  clear  percussion  note,  and  the 
tumor  is  more  prominent  when  he  is  erect  than  when  recum- 
bent. Long  continuation  of  obstructive  disease,  producing 
partial  retention  with  or  without  attacks  of  complete  reten- 
tion, disorganizes  the  kidneys.  Acute  and  complete  retention 
may  induce  rupture  of  the  urethra  or  urinary  suppression. 

Treatment. — In  organic  strictiire  try  to  pass  a  soft  catheter  ; 
if  this  fails,  a  hard  catheter;  if  this  fails,  a  filiform  bougie; 
but  if  the  stricture  is  known  to  be  organic  from  previous 


DISEASES   OF   THE   GENITO-URINARY  ORGANS.      713 

history,  at  once  insert  a  filiform  bougie,  leave  it  in  place,  and 
fasten  it.  The  filiform  bougie  will  act  as  a  capillary  drain, 
and  in  a  few  hours  will  empty  the  bladder.  Then  insert 
another  bougie  beside  the  first,  and  so  on  for  several  days, 
using  also  opium,  ordering  rest  in  bed,  and  making  no 
attempt  to  dilate  the  stricture  forcibly  until  retention  is 
passed  and  inflammation  has  subsided.  If  no  bougie  can  be 
passed,  aspirate  or  perform  cystotomy  (suprapubic  or  peri- 
neal). .  In  spasmodic  stricture  hold  a  good-sized  metal  catheter 
firmly  against  the  face  of  the  spasmed  area:  relaxation  will 
occur  and  the  instrument  will  eventually  pass.  In  iiiflam- 
viatioris  give  a  hot  hip-bath  and  suppositories  of  opium  and 
belladonna,  and  then  use  a  hot  sand-bag  to  the  perineum 
and  hot  poultices  to  the  hypogastrium.  If  these  fail  or  if 
the  symptoms  are  urgent,  pass  a  soft  catheter.  In  the  oc- 
cluded meatus  of  the  new-born  incise  with  a  tenotome.  In 
a  congenital  cyst  of  the  sijius  poculaiis  pass  a  steel  bougie, 
which  will  rupture  the  cyst.  In  complete  phimosis  split  up 
the  prepuce.  In  impacted  stone  try  to  pull  it  out  with  ure- 
thral forceps  ;  if  this  fails,  push  it  in  or  cut.  In  fecal  impac- 
tion scrape  out  with  a  spoon.  In  enlarged  prostate  insert 
a  Coude  catheter  strengthened  by  the  insertion  of  a  filiform 
bougie  nearly  to  the  beak  (Brinton),  or  pass  a  silver  instru- 
ment with  a  large  curve.  In  retention  from  expulsive  defect 
use  a  soft  catheter.  Cases  of  retention  require  warmth,  con- 
finement to  bed,  the  administration  of  laxatives,  free  action  of 
the  skin,  and  the  use  of  such  drugs  as  salol,  boracic  acid,  and 
quinine  to  asepticize  the  urine.  In  some  few  cases  no  instru- 
ment can  be  inserted  in  the  bladder.  In  most  of  such  cases 
aspirate — which  may  be  done  several  times  if  necessary — 
and  in  a  day  or  two,  when  swelling  and  congestion  abate, 
an  instrument  can  be  passed.  A  small  trocar  or  an  aspirator- 
needle  is  pushed  into  the  bladder,  the  trocar  or  needle  being 
inserted  in  tlie  median  line,  just  above  the  pubes,  and  taking 


714  A   MANUAL    OF  SURGERY. 

a  course  downward  and  backward.  The  parts  are  first  pre- 
pared antiseptically,  and  the  puncture  is  dressed  with  iodo- 
form and  collodion.  Rectal  puncture  is  now  obsolete.  The 
perineal  incision  is  not  advocated  for  retention  unless  rupture 
of  the  urethra  has  taken  place.  When  a  catheter  is  used  for 
retention  the  patient  must  be  recumbent  to  minimize  shock. 
Withdraw  only  half  the  urine  retained,  as  complete  emptying 
of  an  over-distended  bladder,  by  suddenly  relieving  pressure, 
renders  the  sufferer  liable  to  venous  rupture  and  to  severe 
hemorrhage.     The  same  rule  maintains  in  tapping. 

Injuries  of  the  Bladder. — This  viscus  is  so  deeply  situ- 
ated, and  the  abdominal  walls  are  so  elastic,  that  it  is  rarely 
injured  when  empty.  If  the  bladder  be  full  and  the  abdomen 
be  tense — which  is  common  in  alcoholic  intoxication — force 
applied  upon  the  abdomen  may  contuse  the  bladder. 

Contusion  of  the  Bladder. — In  this  condition  there  are 
noted  vesical  haematuria,  tenesmus,  an  impediment  to  the 
flow  of  water  because  of  clots,  and  severe  cystitis.  Hemor- 
rhage may  be  very  severe,  and  sepsis  may  arise,  even  causing 
death.  When  contusion  exists  retention  is  relieved  by  a 
clean  soft  catheter ;  if  this  fails  because  of  occlusion  of  the 
eye  of  the  catheter  with  blood-clot,  there  must,  from  time 
to  time,  be  forced  through  the  catheter  by  an  irrigator  a  solu- 
tion of  sodium  bicarbonate  in  cooled  boiled  water.  Gross's 
blood  catheter  can  be  used,  or  the  evacuator  of  Bigelow 
may  be  employed.  The  patient  is  put  to  bed,  a  hot-water 
bag  is  applied  to  the  hypogastrium,  morphia  is  administered 
in  moderate  doses,  the  bladder  is  washed  out  several  times 
a  day  with  boracic-acid  solution  to  disintegrate  and  remove 
blood-clots,  and  the  urine  is  diluted  and  rendered  aseptic  by 
the  stomach  administration  of  salol,  boracic  acid,  and  liquor 
potassii  citratis.  Hemorrhage  usually  ceases  on  relieving 
distention ;  if  it  does  not,  some  more  radical  measure  must 
be  employed  (see  Hcsmatiirid). 


DISEASES   OF   THE    GENITO-URINARY  ORGANS.      715 

Besides  contusions,  the  bladder  may  be  injured  by  bullets  ; 
by  stabs  or  punctures  through  the  abdomen,  the  vagina,  or 
the  uterus ;  or  by  penetration  by  a  fragment  of  a  fractured 
pelvic  bone.  The  symptoms  of  such  conditions  are  those 
of.  rupture  of  the  bladder  (^.  7'.).  In  any  intraperitoneal 
wound,  at  once  open  the  abdomen,  suture  the  wound  in  the 
bladder-wall,  irrigate  the  peritoneal  cavity,  and  drain  the 
bladder  by  means  of  a  retained  catheter,  a  perineal  section, 
or  a  Siiprapubic  cystotomy.  In  an  extraperitoneal  wound, 
drain  the  wound  by  a  tube,  and  drain  the  bladder  by  a  re- 
tained catheter,  a  perineal  section,  or  a  suprapubic  opening. 

Rupture  of  the  bladder  occurs  in  three  forms  :  (i)  intra- 
peritoneal— a  rupture  involving  the  peritoneal  coat ;  (2)  ex- 
traperitoneal— a  rupture  of  a  portion  of  the  bladder  not 
covered  by  peritoneum ;  and  (3)  subperitoneal — a  rupture 
of  the  mucous  and  muscular  coats,  the  urine  diffusing 
under  the  peritoneal  investment.  The  causes  are  of  two 
kinds,  predisposing  and  exciting.  Pi^edisposing  causes  are — 
distention  of  bladder ;  drunkenness  ;  ulceration  ;  degenera- 
tion or  atony  of  the  bladder-coats.  Exciting  causes  are — 
obstruction  to  outflow  of  urine  (by  stricture  or  enlarged 
prostate) ;  external  violence ;  falls  upon  the  feet  and  the 
buttocks,  as  well  as  upon  the  abdomen;  lifting;  straining 
at  stool,  in  micturition,  or  during  parturition  ;  and  the  forcing 
of  injections  into  the  bladder.  This  accident  is  commoner 
in  men  than  in  women  (10  to  i),  and  is  rare  in  children. 

Symptoms,  Diagnosis,  and  Ti^eatment. — The  symptoms  are 
not  always  definite,  and  every  characteristic  one  may  be  for 
a  time  absent,  the  patient  seeming  in  some  rare  instances  to 
possess  the  power  of  retaining  his  urine  and  of  voiding  it. 
As  a  rule,  however,  there  are  found  some  or  all  of  the  follow- 
ing symptoms,  following  an  accident  or  occurring  during  the 
progress  of  a  causative  disease :  collapse ;  excessive  desire 
to  urinate ;  inability  to  do  so ;  a  catheter,  when  used,  brings 


7l6  A   MANUAL    OF  SURGERY. 

away  pure  blood  or  a  very  little  bloody  urine;  the  catheter 
occasionally  slips  through  the  tear  into  a  cavity,  and  more 
bloody  water  comes  away ;  severe  hypogastric  pain  comes 
on  after  a  temporary  sense  of  relief  from  retention ;  shock 
is  so  severe  that  death  may  ensue ;  if  reaction  follows,  there 
is  delirium,  often  septicaemia  and  peritonitis;  extensive  infil- 
trations of  urine  may  occur.  In  intraperitoneal  rupture  gen- 
eral peritonitis  is  certain  to  arise,  but  its  appearance  may 
be  postponed  for  several  days  if  the  urine  is  healthy.  In 
these  cases  the  extravasation  is  noted  as  a  simple  swelling, 
probably  on  one  side  only.  In  extraperitoneal  rupture  the 
urine  may  infiltrate  the  perineum,  the  scrotum,  the  thighs, 
and  under  the  integuments  of  the  abdomen  and  the  back, 
and  may  soon  induce  sloughing.  In  subperitoneal  rupture 
peritonitis  is  apt  to  arise.  Injecting  fluid  fails  to  lift  up  the 
bladder  into  the  hypogastric  region  so  as  to  be  recognizable 
on  percussion.  If  there  is  injected  a  measured  amount  of 
fluid,  less  will  run  out  than  went  in. 

In  all  doubtful  cases  take  a  Davidson  syringe,  tie  a  piece 
of  cotton  over  its  outer  end,  fasten  its  other  end  to  a  soft 
catheter  which  is  inserted  into  the  bladder,  and  pump  in  air 
filtered  to  prevent  infection :  an  unruptured  bladder  will  rise 
above  the  pubes  as  a  pyriform  tumor,  tympanitic  on  percus- 
sion ;  a  ruptured  bladder  will  not  so  rise.  In  intraperitoneal 
rupture  the  general  peritoneal  cavity  will  be  distended  with 
the  air.  In  extraperitoneal  rupture  injection  produces  emphy- 
sema of  the  extravesical  connective  tissues.  On  removing 
the  syringe  the  air  rushes  out  again  if  the  bladder  is  unrup- 
tured, but  little  if  any  comes  away  if  it  is  ruptured.  Senn 
reconmiends  injecting  hydrogen  gas  instead  of  air.  The 
treatment  is  the  same  as  that  for  wounds  of  the  bladder. 

Atony  of  the  bladder  is  a  condition  in  which  the  expul- 
sive power  of  the  bladder  is  diminished  or  lost  because  of 
impairment  of  muscular  tone.     The  bladder  is  very  thin, 


DISEASES   OF   THE    GENITO-URINARY  ORGANS,      yiy 

and  the  muscles  are  flaccid  and  often  the  seat  of  fatty  degen- 
eration. Sometimes  the  bladder  is  very  large  and  sometimes 
it  is  very  small.  A  slight  degree  of  atony  is  physiological 
after  middle  age.  The  causes  are  senility,  distention  from 
true  paralysis,  chronic  over-distention  from  obstruction,  and 
acute  over-distention. 

Symptoms  and  Treatment. — In  atony  of  the  bladder  the 
patient  passes  water  frequently  (a  symptom  probably  exist- 
ing for.  some  years),  and  especially  at  night ;  he  may  even  do 
so  while  asleep.  The  stream,  when  voluntarily  passed,  has 
no  projection,  but  drops  at  once  from  the  end  of  the  penis. 
Retention  is  apt  to  occur  with  incontinence,  and  residual 
urine  exists  for  years,  and  may  at  any  time  set  up  cystitis. 
This  condition  is  not  vesical  paralysis  resulting  from  a  lesion 
of  the  nervous  system.  In  treating  atony  of  the  bladder, 
measure  the  residual  urine :  if  it  amounts  to  four  ounces,  use 
a  soft  catheter  night  and  morning;  if  it  amounts  to  six  ounces, 
use  the  catheter  every  eight  hours ;  if  it  amounts  to  eight 
ounces,  use  the  catheter  every  six  hours  (J.  W.  White).  The 
patient  should  be  taught  how  to  use  the  catheter.  After 
using  it,  it  is  washed  with  soap  and  water,  a  stream  of  water  is 
run  through  it,  it  is  soaked  in  a  i  :  looo  solution  of  corrosive 
sublimate,  is  kept  until  again  wanted  in  a  I  :  40  carbolic  solu- 
tion, and  when  again  needed  is  anointed  with  glycerin.  The 
bladder  is  from  time  to  time  washed  out  with  gr.  iij  to  the 
ounce  of  boracic-acid  solution  at  a  temperature  of  100°  F. 
Strychnine,  electricity,  ergot,  and  cantharides  may  be  ordered. 

Vesical  Calculus,  or  Stone  in  the  Bladder. — The  salts 
normally  in  solution  in  the  urine  may  deposit  as  calculi  and 
may  be  imprisoned  in  any  portion  of  the  urinary  tract.  The 
commonest  calculi  are  those  composed  of  uric  acid,  urates, 
calcium  oxalate,  and  fusible  phosphates.  The  formation  of 
uric-acid  and  urate  calculi  is  explained  under  Renal  Calcu- 
lus (p.  703).     Vesical  calculi  are  usually  renal  calculi  that 


yiS  A   MANUAL    OF  SURGERY. 

have  passed  the  ureter  and  become  enlarged  by  new  accre- 
tions. Phosphatic  calcuH  may  be  formed  in  the  bladder 
when  chronic  cystitis  causes  and  maintains  an  alkaline  urine. 
Uric-acid  calculi  are  smooth,  round  or  oval,  and  hard, 
but  easily  broken.  On  section  they  present  the  color  of 
brick-dust  and  are  marked  by  concentric  rings.  Their  nu- 
clei are  dark  by  comparison.  They  are  soluble  in  dilute 
potassium  hydrate,  and  with  effervescence  in  nitric  acid. 
They  arc  combustible,  and  leave  scarcely  any  ash.  Urate 
of  sodium  and  urate  of  ammonium  often  occur  together  in 
stones,  and  these  calculi  are  not  in  rings,  are  not  so  hard 
as  the  uric-acid  stones,  and  are  fawn-colored  on  section. 
Oxalate-of-lime  stones  are  round  with  many  projecting  nodes 
like  the  mulberry,  hence  the  term  "  mulberry  calculus."  They 
are  very  hard,  and  section  shows  the  color  to  be  brown  or 
green,  and  that  they  possess  wavy  concentric  rings.  This 
form  of  calculus  is  soluble  in  hydrochloric  acid.  Fusible 
calculus,  which  is  composed  of  magnesic  ammonic  phos- 
phate with  phosphate  of  lime,  constitutes  the  commonest 
form  of  phosphatic  stones  and  of  large  stones.  It  is  light, 
soft,  smooth,  and  white,  and  shows  no  laminae  on  section. 
Some  rare  forms  of  stone  are  composed  of  xanthic  oxide, 
cystic  oxide,  calcium  phosphate  or  carbonate,  and  magnesic 
ammonic  phosphate  (triple  phosphate). 

A  stone  may  be  formed  having  layers  of  different  sub- 
tances ;  for  instance,  there  is  often  found  a  uric-acid  nucleus 
surrounded  by  phosphates,  the  latter  surrounded  by  uric 
acid  or  urates,  and  these  again  by  phosphates.  In  some 
cases  oxalate  of  lime  alternates  with  uric  acid,  urates,  or 
phosphates  (Bowlby).  Bowlby  states  that  the  alternating 
uric-acid  and  phosphatic  layers  are  due  to  the  altering  reac- 
tions of  the  urine ;  that  when  the  urine  is  acid,  uric  acid 
is  deposited  on  the  stone,  but  when  cystitis  makes  the  urine 
alkaline  the  stone  receives  a  phosphatic  coat. 


DISEASES   OF  THE    GENITO-URINARY  ORGANS.      719 

Anything  that  favors  the  formation  of  an  excessive  uri- 
nary deposit  may  cause  vesical  calculus,  such  as  defective 
digestion,  failure  in  processes  of  oxidation,  excess  of  solids 
and  nitrogenous  elements  in  the  diet,  deficient  exercise,  etc. 
If  to  the  urinary  condition  established  by  the  above  condi- 
tions a  catarrh  of  the  genito-urinary  tract  occurs,  pus  or 
muco-pus  in  concentrated  urine  may  induce  stone.  Children 
are  predisposed  to  uric-acid  stones,  and  old  people  to  phos- 
phatic .  stones.  In  an  old  man  with  enlarged  prostate  and 
chronic  cystitis  a  stone  forms  easily  about  any  accidental 
nucleus.  The  nucleus  may  be  some  phosphate-crystals 
glued  up  by  mucus,  may  be  a  blood-clot,  some  uric-acid 
gravel,  or  some  foreign  body.  Stone  is  rare  in  females, 
because  of  the  shortness,  the  large  diameter,  and  the  ready 
dilatability  of  the  urethra.  Stone  is  very  rare  in  the  negro. 
Gout,  rheumatism,  lithaemia,  enlarged  prostate,  vesical  atony, 
urethral  stricture,  and  catarrhal  inflammation  of  the  kidney, 
the  ureter,  and  the  bladder,  are  predisposing  causes. 

Symptoms. — In  not  a  few  cases  the  vesical  symptoms  are 
antedated  by  an  attack  of  nephritic  colic.  The  severity  of 
the  symptoms  depends  more  on  the  roughness  of  the  stone 
than  on  its  size.  Small  rough  calculus  will  produce  intoler- 
able anguish,  whereas  several  large  smooth  stones  will  cause 
but  moderate  pain.  A  patient  with  stone  in  the  bladder 
complains  of  frequency  of  micturition,  particularly  in  the 
day-time,  the  desire  being  sudden,  uncontrollable,  and  invoked 
or  aggravated  by  exercise.  This  symptom  is  more  positive 
in  youth  than  in  old  age.  Pain  of  a  sharp,  burning  charac- 
ter is  experienced  at  the  end  of  micturition,  due  to  the  con- 
traction of  the  empty  bladder  upon  the  stone.  The  usual 
seat  of  this  pain  is  the  under  surface  of  the  head  of  the  penis, 
a  little  behind  the  meatus,  and  the  pain  may  continue  for 
some  time.  By  pulling  on  the  penis  to  relieve  this  pain  the 
prepuce   often   becomes   pendulous.      This    pain   varies   in 


720  A    MANUAL    OF  SURGERY. 

severity,  being  worse  during  cystitis  and  after  exercise ;  it 
may  be  absent  in  encysted  stone,  it  may  even  almost  disap- 
pear, and  it  is  always  worse  in  the  young  than  in  the  old. 
Stone  in  chronic  cases  of  atony  and  in  cases  of  vesical 
paralysis  causes  neither  marked  pain  nor  frequency  of 
micturition.^  Attacks  of  cystitis  in  a  man  with  calculus 
are  spoken  of  as  attacks  of  stone.  When  a  stone  is  small  it 
may  during  micturition  roll  into  the  urethral  orifice,  and  so 
cause  a  sudden  interruption  of  the  flow  of  water,  the  stream 
again  starting  when  the  patient  changes  his  position.  This 
symptom  is  rare  in  the  old,  the  stone  in  them  dropping  into 
the  sac  back  of  the  prostate  and  below  the  urethral  orifice. 
Haematuria  may  or  may  not  be  noted  ;  it  is  most  usual  after 
exercise,  and  is  noted  at  the  end  of  the  urinary  act.  Pus  or 
muco-pus  will  be  noted  if  cystitis  occurs.  Priapism  occurs 
in  some  cases.  Pain  of  a  reflex  nature  may  be  felt  in  the 
rectum,  in  the  perineum,  or  in  some  distant  part. 

The  above  symptoms,  even  if  all  are  present,  do  not  prove 
the  individual  to  have  a  stone  in  the  bladder.  To  prove  the 
presence  of  a  stone,  it  must  be  touched  with  a  sound  and 
the  contact  must  be  felt  and  heard.  To  sound  a  patient,  have 
the  bladder  well  filled  with  water,  and  place  him  recumbent 
with  the  knees  drawn  up.  Never  sound  a  person  while  he 
is  standing,  because  of  the  danger  of  syncope.  In  an  ordi- 
nary case  use  a  sound  with  a  very  slight  curve ;  in  a  man 
with  hypertrophied  prostate  use  a  sound  with  a  short  and 
decided  curve.  The  calibre  of  a  stone-sound  is  a  No.  13 
French.  Examine  the  entire  bladder  systematically,  and 
never  operate  unless  a  stone  be  both  heard  and  felt.  The 
stone  may  be  hard  to  find,  or  it  may  elude  the  instrument 
entirely  when  it  is  encysted,  when  it  rests  in  a  diverticulum, 
when  it  is  fixed  to  the  roof  or  anterior  wall  of  the  viscus,  or 
when  it  is  crusted  with  lymph  or  blood-clot.     In  doubtful 

^  American  Text-Book  of  Surgery. 


DISEASES   OF   THE    GENITO-URINARY  ORGANS.      72 1 

cases  always  insist  on  a  second  examination,  giving  ether  if 
the  first  was  very  painful.  Occasionally  a  small  stone  will 
be  found  by  using  a  Bigelow  evacuator,  the  current  causing 
the  calculus  to  knock  against  the  tube.  A  stone,  when  it  is 
detected,  should  always  be  measured  by  an  arrangement  like 
a  lithotrite.  The  composition  of  the  stone  is  assumed  from 
an  examination  of  fragments  which  pass  by  the  urethra  or 
which'  adhere  to  the  measure.  Remember  that  the  outer 
rind  of  a  calculus  may  be  soft  phosphate  and  the  inner  por- 
tion may  be  hard  uric  acid,  urates,  or  oxalates.  Examine 
for  stone  in  females  with  a  straight  sound,  and  in  cases  of 
uncertainty  dilate  the  urethra  and  explore  the  bladder  with 
the  little  finger. 

Treatment. — In  people  predisposed  to  stone  (for  instance, 
by  lithaemia)  the  surgeon  should  foresee  the  danger  and  essay 
to  antagonize  it.  Insist  on  the  urine  being  kept  dilute  by  the 
freest  use  of  water  and  of  milk,  and  reduce  to  a  minimum 
alcohol,  meat,  sugar,  and  fat.  Let  the  patient  live  on  green 
vegetables,  salads,  bread,  fruit,  eggs,  fish,  poultry,  weak  tea 
or  coffee,  water,  milk,  and,  if  desired,  a  little  red  wine.  Con- 
tinued purging  does  harm  by  concentrating  the  urine,  though 
a  laxative  may  be  employed  when  indicated.  Moderate 
open-air  exercise  is  of  immense  importance,  sunshine  and 
fresh  air  being  Nature's  correctives  for  a  condition  of  imper- 
fect oxidation  power.  If  the  urine  be  very  acid,  use  piper- 
azine,  grs.  xv  to  grs.  xxiv  daily,  liquor  potassii  citratis,  phos- 
phate of  sodium,  or  borocitrate  of  magnesium.  If  the  urine  be 
phosphatic,  order  mineral  acids  and  strychnine.  If  the  urine 
be  filled  with  oxalate,  use  the  mineral  acids  with  an  occasional 
course  of  phosphate  of  sodium.  Travel  and  rest  at  the  sea- 
side or  at  some  spa  are  often  of  service  in  all  forms.  Always 
endeavor  to  prevent  cystitis,  and  treat  it  at  once  when  it  does 
occur.  When  a  stone  is  once  formed,  it  is  an  idle  dream  to 
think  of  dissolving  it.     An  operation  must  be  done.     The 

46 


722  A   MANUAL    OF  SURGERY. 

operation  selected  depends  upon  the  age,  the  state  of  the 
bladder  and  the  prostate,  the  dilatability  of  the  urethra,  the 
kidney  condition,  and  the  size  and  composition  of  the  stone 
(see  Opcvatwus  on  tlic  B/addcj). 

Cystitis. — Inflammation  of  the  bladder  is,  as  a  rule,  a 
complication  of  some  other  disease  of  the  genito-urinary 
tract,  but  it  can  arise  from  cold  and  wet.  Traumatism  from  a 
catheter,  the  presence  of  a  stone,  the  spread  of  a  urethral 
inflammation,  pus  infection,  the  existence  of  tuberculosis  or 
cancer,  and  the  use  of  such  a  drug  as  cantharides,  can  pro- 
duce it.  It  appears  not  unusually  during  an  exanthematous 
fever  or  in  conditions  of  vesical  paralysis ;  it  often  follows 
retention,  frequently  accompanies  enlarged  prostate  and 
urethral  stricture,  and  sometimes  arises  from  concentration 
of  urine  or  accompanies  growths.  Acute  cystitis  causes 
discoloration  and  swelling  of  the  bladder-walls,  and  there 
is  present  a  catarrhal  discharge  which  is  mixed  with  urinary 
elements,  serum,  mucus,  often  pus  and  epithelial  debris.  Ul- 
ceration, sloughing,  or  false-membrane  formation  may  occur. 

In  chronic  cystitis  there  is  an  enormous  production  of  thick, 
sticky  mucus  and  the  urine  becomes  alkaline.  The  exces- 
sive secretion  of  mucus  and  the  great  number  of  bacteria  con- 
vert the  urea  into  carbonate  of  ammonia,  and  this  production, 
being  irritant  to  the  bladder-walls,  makes  the  inflammation 
worse.  In  chronic  cystitis  the  bladder  is  contracted  and  has 
very  thick  walls,  and  the  mucous  membrane  is  thick,  oedem- 
atous,  congested,  and  filled  with  large  veins.  The  bladder 
may  be  ulcerated  or  be  encrusted  with  urinary  salt.  The 
urine  contains  triple  phosphate,  pus,  blood,  and  mucus,  the 
blood  emerging  with  the  last  drops  of  water. 

Symptoms  of  Acute  Cystitis. — Great  frequency  of  micturi- 
tion, with  the  passage  at  each  act  of  very  small  quantities  of 
urine;  the  desire  to  urinate  is  almost  constant,  and  there  is 
intensely  painful    straining  (tenesmus).     The  pain  is  acute 


DISEASES   OF   THE    GENITO-URINARY  ORGANS.      723 

and  scalding,  and  may  be  felt  above  the  pubes  or  in  the 
perineum ;  the  pain  often  runs  into  the  loins  and  the  thighs 
and  radiates  over  the  sacrum.  Pain  above  the  pubes  indi- 
cates involvement  of  the  fundus,  and  pain  in  the  perineum 
and  the  head  of  the  penis  points  to  inflammation  of  the 
bladder-neck.  The  urine,  at  first  clear,  loses  its  transparency, 
becomes  full  of  thick  mucus,  and  often  contains  a  little  blood 
or  pus.  The  patient  not  unusually  has  some  fever.  A  rectal 
examination  causes  fearful  pain.  If  ischuria  takes  place  there 
will  be  a  chill  and  high  fever,  and  aucxmia  may  appear  or 
vesical  rupture  may  ensue. 

Treatment. — In  treating  acute  cystitis,  try  to  remove  the 
cause.  If  cystitis  arises  from  the  administration  of  canthar- 
ides,  put  the  patient  in  bed  and  give  him  liquor  potassii 
citratis.  If  it  comes  from  the  use  of  a  clean  sound,  order 
rest  in  bed,  suppositories  of  opium  and  belladonna,  diluent 
drinks,  and  the  use  of  ammonii  benzoas  or  of  lupulin.  If 
the  inflammation  is  septic  (as  from  the  use  of  a  dirty  sound) 
or  is  very  acute,  put  the  patient  in  bed,  keep  him  warm,  and 
use  a  hot  sand-bag  to  the  perineum  and  hot  fomentations  or 
poultices  to  the  hypogastrium.  Hot  hip-baths  may  be  used. 
The  hips  had  best  be  elevated  and  the  bowels  be  emptied  by 
salines  and  glycerin  enemata.  An  exclusive  milk  diet  is 
desirable.  The  patient  should  drink  copiously  of  sweetened 
water  containing  a  few  drops  of  aromatic  sulphuric  acid  or 
of  milk  of  almonds.  An  excellent  remedy  is  the  combina- 
tion of  equal  parts  of  the  infusion  of  herba  herniari?E  and 
chenopodium  ambrosioides,  three  glassfuls,  sweetened  with 
sugar,  being  given  every  day  (Von  Zeissl).  If  the  pain  and 
straining  still  continue,  order — 

R.  Ext.  sem.  hyoscyamin.,  grs.  viij ; 

Ext.  cannabis  indicne,  grs.  viij ; 

Sacchar.  alba,  grs.  xlviij. — M. 

Di\'%  in  pulv.  No.  xx. 
Sig.  One  powder  every  three  hours.  (Von  Zeissl.) 


724  ^   MANUAL    OF  SURGERY. 

Or, 

R .  Camphora,  grs.  viij ; 

Ext.  cannabis  indicae,  grs.  viij ; 

Saccliar.  alba,  grs.  xlviij. — M. 

Div.  in  pulv.  No.  xx. 
Sig.  One  powder  every  three  hours.  (Von  Zeissl.) 

Suppositories  of  extract  of  belladonna  are  of  great  value. 
If  these  remedies  fail,  the  surgeon  will  be  driven  to  opium, 
which,  unfortunately  constipates ;  when  it  is  used,  secure 
evacuations  by  glycerin  suppositories  or  by  enemata.  Give 
a  suppository  containing  gr.  j  of  powdered  opium  and  gr.  \ 
of  the  extract  of  belladonna  every  three  or  four  hours. 
Hypodermatic  injections  of  morphia  may  be  required.  If 
retention  occurs,  use  a  soft  catheter.  If  much  blood  is 
passed,  give  internally  the  tinctura  ferri  chloridi  and  blister 
the  perineum.  A  very  acute  cystitis  is  rarely  arrested  within 
a  week  or  ten  days. 

Symptoms  of  Chronic  Cystitis. — This  condition  may  be  a 
legacy  from  acute  cystitis,  or  it  may  appear  without  any 
acute  precursory  phenomena.  There  will  be  found  frequency 
of  micturition,  but  not  so  great  as  in  the  acute  form  ;  there 
will  be  slight  tenesmus,  and  moderate  pain  from  time  to  time, 
running  toward  the  head  of  the  penis.  Constitutional  symp- 
toms arise  only  when  kidney-damage  has  become  pronounced 
or  sepsis  has  occurred  from  absorption.  The  urine  is  ammo- 
niacal,  fetid,  and  turbid ;  it  is  filled  with  viscid,  tenacious 
mucus  or  with  muco-pus ;  it  contains  a  great  excess  of 
phosphates,  and  occasionally  clots  of  blood.  This  condition 
of  chronic  cystitis  with  the  production  of  immense  quanti- 
ties of  thick  mucus  is  often  called  "  chronic  catarrh  of  the 
bladder."  This  state  of  the  bladder  may  eventuate  in  the 
formation  of  stone  or  in  the  production  of  serious  diseases 
of  the  bladder,  the  ureters,  and  the  kidneys.  It  often  occa- 
sions retention. 


DISEASES   OF   THE    GENITOURINARY  ORGANS.      725 

Treatment. — In  treating  chronic  cystitis,  remove  the  cause 
if  possible,  get  rid  of  a  stone,  frequently  evacuate  residual 
urine,  dilate  a  stricture,  and  remov^e  a  tumor.  For  chronic 
cystitis  there  are  used  certain  remedies  by  the  mouth.  Water 
is  drunk  in  large  amounts,  also  iron  spring-water  (Marienbad, 
etc.).  Salol  and  boracic  acid,  gr.  v  of  each  four  times  a 
day,  are  very  valuable.  Salol  in  fluid  extract  of  triticum 
repens  does  good ;  so  does  chlorate  of  potassium,  gr.  x 
daily.-  Astringents  such  as  alum,  tannic  acid,  and  uvae-ursi 
leaves  arrest  mucus-formation.  Copaiba,  cubebs,  buchu,  uva 
ursi,  and  turpentine  have  all  been  recommended.  Whatever 
remedy  is  used,  see  that  the  bladder  is  emptied  of  residual 
urine,  using  a  soft  instrument  several  times  a  day.  Cham- 
pagne and  beer  must  be  avoided  in  chronic  cystitis.  If  the 
above  plan  fails,  irrigate  the  bladder  daily  with  peroxide  of 
hydrogen  (25  to  40  per  cent,  solution),  nitrate  of  silver 
(2  per  cent.),  boric  acid  (5  to  10  per  cent.),  carbolic  acid 
(i  :  500),  corrosive  sublimate  (from  i  :  5000  to  I  :  20,000),  or 
permanganate  of  potassium  (i  to  4  per  cent.).  If  silver  or 
permanganate  of  potassium  is  used,  first  rinse  out  the  blad- 
der with  distilled  water.  If  any  other  agent  is  used,  first 
wash  out  the  bladder  with  boiled  water.  Some  surgeons 
occasionally  use,  at  intervals  of  a  number  of  days,  strong 
silver  solutions  (30  or  40  grains  to  the  ounce).  If  this  solu- 
tion is  used,  after  the  drug  runs  out,  wash  out  the  bladder 
with  a  solution  of  common  salt.  The  bladder  is  washed  out 
by  attaching  to  a  soft  catheter  a  tube  which  is  connected 
with  a  graduated  bottle,  the  force  being  obtained  by  elevating 
the  reservoir  (fountain  irrigation).  If  these  methods  fail  and 
the  patient's  health  is  breaking  down,  drain  by  perineal  or 
suprapubic  cystotomy  (see  Perifieal  Section,  p.  7^^)  and  wash 
the  bladder  through  the  incision  frequently  and  thoroughly. 

Tumors  of  the  Bladder. — These  tumors  may  be  either 
innocent    or    malignant,    the    latter   being   the    commonest. 


726  A    MANUAL    OF  SURGERY. 

Innocent  tumors  are  papillomata  or  villous  tumors,  mucous 
polypi,  and  fibrous  polypi ;  malignant  tumors  are  sarcoma 
(rare)  and  carcinoma  (encephaloid,  rare,  epithelioma,  com- 
mon). 

Symptoms  and  Treatment. — The  innocent  tumors  rarely 
cause  cystitis  or  irritation,  though  by  obstructing  the  ureters 
or  the  urethra  they  may  induce  disease  of  the  kidneys. 
Often  hemorrhage  is  the  only  phenomenon  produced  by  a 
papilloma  or  a  mucous  polyp.  Malignant  tumors  cause 
cystitis,  and  the  urine  contains  mucus,  blood,  and  pus. 
Innocent  tumors  are  hard  to  feel  with  the  sound,  but  ma- 
lignant tumors  are  easily  felt.  The  bleeding  in  bladder- 
growths  is  apt  to  be  profuse,  and  it  occurs  intermittently. 
Bleeding  follows  the  use  of  a  sound.  The  urine  should  be 
examined  microscopically  to  see  if  it  contains  villi,  portions 
of  fibroma,  colonies  of  cancer-cells,  or  fragments  of  epitheli- 
oma (White).  The  use  of  Leiter's  cystoscope  may  aid  the 
surgeon,  but  it  is  scarcely  yet  a  perfected  instrument.  In 
doubtful  cases  exploratory  suprapubic  cystotomy  is  advisable. 
The  treatment  is  by  suprapubic  cystotomy  and  removal  of 
the  growth.  The  perineal  operation  only  enables  the  sur- 
geon to  reach  and  remove  growths  of  small  size,  peduncu- 
lated growths,  and  growths  near  the  neck  of  the  bladder 
(see  Operations  on  the  Bladder^. 

Operations  on  the  Bladder  :  Lateral  Lithotomy. — Lith- 
otomy is  the  removal  of  a  stone  from  the  bladder.  Lateral 
litJiotomy  is  an  operation  which  is  every  year  becoming  less 
popular,  but  which  is  still  employed  by  many  famous  sur- 
geons, especially  for  stone  in  children.  This  operation  should 
not  be  performed  if  the  stone  is  over  two  inches  in  its  short 
diameter;  it  is  rarely  justifiable  if  the  stone  weighs  three 
ounces  or  over  (Cage) ;  and  it  must  not  be  performed  for  en- 
cysted stone,  or  on  a  person  with  a  deep  perineum,  a  narrow 
pelvic  outlet,  or  an  enlarged  prostate.     For  one  week  before 


DISEASES   OF  THE    GEXITO-URIXARY  ORGANS.      727 

the  operation  keep  the  patient  in  bed,  wash  out  the  bladder 
daily  with  hot  boracic-acid  solution,  and  administer  salol  and 
boracic  acid  by  the  mouth,  gr.  v  of  each  four  times  a  day. 
The  night  before  the  operation,  give  a  saline,  order  a  hot 
bath,  and  have  the  perineum,  the  scrotum,  the  buttocks,  and 
the  inner  sides  of  the  thighs  cleansed  and  dressed  antisep- 
tically.  In  the  morning  an  enema  is  to  be  given.  At  the 
time  of  operation  the  bladder  should  contain  some  ounces 
of  urine.  The  instruments  required  are  a  lithotomy-knife, 
a  straight  probe-pointed  bistoury,  a  grooved  staff,  a  stone- 
sound,  scoops  and  stone-forceps,  a  tenaculum,  an  aneurysm- 
needle,  a  fountain  syringe,  curved  needles  and  a  needle- 
holder,  haemostatic  forceps,  a  tube  with  chemise  (Fig.  41), 
a  Pacquelin  cautery,  a  Clover  crutch,  and  a  lithotrite. 

In  performing  the  operation^  place  the  patient  upon  his 
back  and  find  the  stone  by  sounding.  If  the  stone  is  not  dis- 
covered by  the  sound,  do  not  operate.  Pull  the  buttocks  over 
the  end  of  the  table,  introduce  the  staff,  flex  the  legs  and 
thighs,  and  fasten  the  patient  in  the  lithotomy  position  with 
a  crutch.  During  the  first  incision  the  handle  of  the  staff  is 
held  toward  the  belly ;  after  the  first  cut  the  staff  is  set 
perpendicularly  and  is  hooked  up  under  the  pubes.  An  in- 
cision is  made,  starting  just  to  the  left  of  the  raphe  and  one 
and  a  quarter  inches  in  front  of  the  edge  of  the  anus,  and 
passing  downward  and  outward  to  betvv^een  the  anus  and  the 
ischial  tuberosity,  but  one-third  nearer  the  former  than  the 
latter.  In  the  adult  this  incision  is  three  inches  long.  The 
first  incision  is  superficial  and  does  not  reach  the  staff,  but 
it  is  this  incision  which  may  cut  the  rectum.  After  making 
the  first  cut  the  nail  of  the  left  index  finger  feels  for  the 
groove  of  the  staff  the  staff  is  hooked  up,  the  knife  is 
entered  into  the  groove  and  is  pushed  into  the  bladder, 
and  as  it  is  withdrawn  the  wound  is  enlarged.  As  the 
knife  enters  the  bladder  there  is  a  gush  of  fluid.     The  finger 


728  A   MANUAL    OF  SURGERY. 

follows  the  knife  and  stretches  the  wound,  the  staff  is  with- 
drawn, and  the  stone  is  felt  for  and  extracted.  In  with- 
drawing the  stone,  make  traction  in  the  axis  of  the  pelvis, 
and  do  not  rotate  the  calculus  until  it  is  entirely  out  of 
the  prostatic  urethra.  Wash  or  scrape  away  debris  or  in- 
crustation, see  that  no  other  stone  is  present,  syringe  out 
the  bladder  with  hot  corrosive-sublimate  solution  (i  15000), 
insert  a  tube,  apply  antiseptic  dressings  around  the  tube, 
and  put  on  a  T-bandage.  The  end  of  the  tube  which  is 
external  to  the  dressings  is  fastened  to  the  tails  of  the 
T-bandage.  A  rubber  cloth  is  put  on  the  bed,  under  the 
body  and  legs,  and  the  patient's  buttocks  rest  upon  a  mass 
of  old  linen,  the  scrotum  being  raised  on  a  pad.  The  knees 
are  bent  over  pillows.  Change  the  linen  as  soon  as  it 
becomes  wet.  Remove  the  tube  in  forty-eight  hours.  The 
urine  begins  to  come  by  the  urethra  from  the  eighth  to  the 
twelfth  day.  In  children  the  incision  is  not  so  long  and  is 
dilated  with  forceps  instead  of  with  the  finger ;  no  tube  is 
required.  In  lateral  lithotomy  the  prostatic  and  membranous 
urethra  are  opened,  the  prostate  gland  is  partly  divided  with 
the  knife,  and  the  wound  is  dilated  with  the  finger. 

Suprapubic  Lithotomy. — This  operation  is  the  removal 
of  a  stone  through  an  opening  over  the  pubes.  It  is  in 
many  instances  the  preferable  operation.  It  is  used  for  the 
removal  of  multiple  calculi,  for  very  hard  stones,  for  stones 
above  one  and  a  half  inches  in  diameter,  for  calculi  in  men 
with  enlargement  of  the  prostate,  for  foreign  bodies  incrusted 
with  sediment,  when  the  perineum  is  deep,  when  the  pelvic  out- 
let is  narrow,  and  when  the  urethra  will  not  permit  the  use  of 
a  lithotrite.  The  patient  is  prepared  as  for  lateral  lithotomy, 
except  that  the  pubes  are  shaved  and  the  lower  part  of  the 
abdomen  and  the  upper  part  of  the  thighs  are  disinfected. 
During  the  operation  the  penis  is  covered  with  an  antiseptic 
cloth.     The   instruments   required    are   a   scalpel,   a  probe- 


DISEASES   OF  THE    GENITO-UK INARY  ORGANS.      729 

pointed  bistoury,  scissors,  a  tenaculum,  blunt  hooks,  haemo- 
static forceps,  retractors,  dissecting-forceps,  a  dry  dissector, 
an  electric  forehead-light,  a  rectal  bag,  a  brass  syringe, 
a  sound,  rubber  tubing,  rubber  catheters,  stone-forceps  and 
scoops,  a  bladder-tube,  curved  needles  and  a  needle- holder, 
and  a  graduated  glass  jar  for  injecting  the  bladder. 

In  performing  the  operation,  place  the  patient  in  the  Tren- 
delenburg  position   (Fig.    146).      Have  an  assistant   oil   the 
rectal  bag  and  push  it  above  the  sphincters.     Draw  off  the 
urine  with  a  soft  catheter,  wash  out  the  bladder  with  warm 
boracic-acid   solution   (i  :  32),   and   inject  the  bladder  with 
the  same  solution.     In  a  child  under  the  age  of  five  inject 
three   to    four    ounces ;    in    an    adult    inject    ten    to    twelve 
ounces.      Withdraw    the    catheter,  and    tie    a    tube    around 
the  penis  to  prevent    the  escape  of  fluid.    Some   surgeons 
simply  inject  air  by  means  of  a  catheter  and  a  brass  syringe 
or  a  Davidson  syringe.     After  injecting  the  bladder,  if  the 
viscus  is  not  well  lifted  up,  inject  the  rectal  bag  and  clamp 
its   tube  with  forceps.     In  a  child  inject  from  two  to  four 
ounces  of  warm  water;  in  an  adult  inject  ten  ounces.     Make 
a  three-inch  incision  in  the  median  line  of  the  hypogastric 
region,  terminating  over  the  symphysis.     When    the   peri- 
vesicular  connective  tissue  is  reached,  cut  it.     If  the  peri- 
toneum   should    appear,    push    it    up.       Hold    the    wound- 
edges  apart  by  retractors.     The  large  veins  are  seen,  giv- 
ing the   bladder  a  blue  color.      Avoid  these  veins  if  pos- 
sible, but    even  if  they  should  be  cut   bleeding  will   stop 
when  the  bladder  is  opened  and  the  rectal  bag  is  removed. 
Clamp  bleeding  vessels ;  catch  the  bladder  transverseh-  with 
a  tenaculum  at  the  upper  angle  of  the  wound  ;   open  the 
viscus  in  the  middle  line  above,  and  cut  toward  the  pubes ; 
catch  the  edges  of  the    cut  with   haemostatic  forceps,  and 
remove  the  tenaculum.     Explore  the  bladder,   remove  the 
stone  or  stones,  scrape  away  incrustations,  ligate  bleeding 


730  A    MANUAL    OF  SURGERY. 

vessels  outside  the  bladder,  and  irrigate  the  viscus  with  hot 
bichloride-of-mercury  solution  (i  :  5000).  Introduce  a  tube 
into  the  bladder,  and  attach  to  its  external  end  a  long  tube 
to  siphon  off  the  urine.  Suture  the  muscles  and  fascia  at 
the  upper  part  of  the  wound,  but,  as  a  rule,  do  not  suture 
the  bladder.  Bladder-sutures  rarely  hold,  and  become  in- 
crusted  with  urinary  salts.  Dress  with  dry  antiseptic  gauze 
and  a  rubber  dam,  the  dressings  and  binder  being  split  to  go 
around  the  tube.  Catch  the  urine  which  siphons  over  in  a 
bottle  containing  some  antiseptic  fluid.  Change  the  dress- 
ings as  often  as  they  become  wet.  Take  out  the  tube  in  four 
or  five  days,  and  allow  the  wound  to  heal  by  granulation. 

Crushing-  of  Vesical  Calculi. — This  is  now  done  in  one 
sitting,  the  old  operation  of  Civiale,  requiring  repeated  crush- 
ings,  being  obsolete. 

Litholapaxy  (Bigelow's  operation,  or  rapid  lithotrity)  is 
the  operation  for  removing  a  stone  in  the  bladder  in  one  sit- 
ting by  thoroughly  crushing  the  stone  and  completely  wash- 
ing away  the  fragments.  Sir  H.  Thompson  says  this  method 
is  suited  to  twenty-nine  cases  out  of  thirty.  Litholapaxy 
should  be  employed  if  the  bladder  will  hold  at  least  six 
ounces  of  fluid  and  is  in  a  fairly  healthy  condition  ;  if  the 
urethra  is  tolerant  and  penetrable  by  instruments ;  if  the 
stone  is  not  too  hard,  does  not  weigh  over  two  and  three- 
quarter  ounces,  and  is  not  over  two  inches  in  diameter.  It 
is  not  suited  for  multiple  calculi,  for  large  and  hard  calculi, 
for  encysted  stones,  or  for  a  patient  with  enlarged  prostate, 
with  vesical  atony,  or  with  cystitis.  An  easily  dilatable  stric- 
ture need  not  prevent  the  surgeon  from  doing  litholapaxy. 
The  stricture  can  first  be  dilated,  and  later  Bigelow's  opera- 
tion can  be  performed,  but  firm,  gristly  strictures  demand  a 
cutting  operation.  If  the  urethra  is  intolerant  of  instrumen- 
tation, the  patient  being  prone  to  febrile  attacks  when  it  is 
attempted,  cut    instead    of  crushing.     People    with    kidney 


DISEASES   OF   THE    GENITO-URINARY  ORGANS.      73 1 

disease  will  do  better  after  this  operation  than  after  cutting 
(Cage).  In  diabetes,  locomotor  ataxia,  and  conditions  of 
exhaustion  patients  are  best  treated  by  Bigelow's  operation, 
unless,  cystitis  exists. 

The  preparation  of  the  bladder  is  the  same  as  for  lithotomy. 
Be  sure  to  measure  the  stone,  and  to  ascertain  also  whether 
a  lithotrite  can  readily  be  introduced  and  manipulated.  The 
instruments  required  are  a  stone-sound,  lithotrites  (several 
sizes),  an  evacuating-bulb  and  tubes  (straight  and  curved),  soft 
catheters,  a  glass  irrigator  to  inject  the  bladder,  and  instru- 
ments in  case  the  surgeon  is  forced  to  cut.  The  patient  is 
anaesthetized  and  is  placed  upon  his  back,  a  pillow  is  inserted 
under  the  pelvis,  and  he  is  well  wrapped  up.  The  urine  is 
drawn  and  a  measured  amount  of  warm  boracic  acid  is 
allowed  to  flow  into  the  bladder.  This  plan  is  better  than 
having  the  patient  retain  his  urine,  as  in  the  latter  case  there 
is  no  certainty  as  to  the  amount  of  fluid  in  the  viscus.  It  is 
well  to  introduce  at  least  five  or  six  ounces  of  fluid  if  pos- 
sible. If  the  bladder  will  not  hold  four  ounces,  the  operation 
is  unsafe  (Thompson).  The  lithotrite  is  now  introduced, 
the  handle  being  gradually  raised  to  a  vertical  position  as 
the  penis  is  drawn  up  on  the  shaft,  but  not  being  depressed 
until  the  instrument  has  passed  by  its  own  weight  into  the 
prostatic  urethra.  Thompson's  plan  for  catching  the  stone 
is  as  follows  :  After  introducing  the  lithotrite,  let  its  lower 
end  rest  for  a  few  seconds  on  the  bottom  of  the  bladder,  so 
that  currents  will  subside  ;  then  draw  back  the  male  blade, 
wait  a  second,  close  it  again,  and  in  almost  every  instance  the 
stone  is  caught.  If  the  stone  is  caught,  press  firmly  to  see  that 
the  calculus  is  well  held,  lock  the  instrument,  and  break  the 
foreign  body  by  screwing.  When  resistance  suddenly  ceases 
the  stone  has  either  slipped  or  has  been  crushed  ;  if  crushed 
the  blades  should  have  been  felt  forcing  through  the  stone 
and  the  calculus  should  have  been  heard  to  break.     When 


732  A   MANUAL    OF  SURGERY. 

resistance  ceases  catch  and  crush  again  as  above  directed. 
Rapid  movements  with  the  Hthotrite  are  improper,  as  they 
estabhsh  currents  which  are  apt  to  push  away  the  stone.  If 
the  above  manoeuvre  does  not  catch  the  stone,  see  if  the  cal- 
culus be  near  the  neck  of  the  bladder.  Pull  the  instrument 
close  to  the  vesical  neck,  and  open  it,  not  by  pulling  the 
male  blade,  but  by  pushing  the  female  blade.  If  the  operator 
still  fails  to  catch  the  stone,  or  if,  after  crushing,  a  large  frag- 
ment knocks  against  the  evacuator,  which  fragment  cannot 
pass,  conduct  a  careful  search  :  turn  the  blades  to  the  right 
side,  open,  and  close ;  then  to  the  left  side,  open,  and  close  ; 
next  turn  the  point  around  behind  the  prostate,  open,  and 
close.  In  these  side  turns  of  the  lithotrite,  in  order  to  crush, 
turn  the  instrument  very  slowly,  so  as  to  detect  the  catching 
of  the  bladder-wall  if  it  has  occurred,  and  crush  the  stone  in 
the  middle  of  the  bladder  with  the  blades  up.  After  crush- 
ing several  times,  proceed  to  evacuate.  Fill  the  aspirator 
with  warm  boiled  water  or  with  warm  solution  of  carbolic 
acid  (lO  m.  to  the  pint).  Insert  an  evacuating  catheter,  its 
point  being  in  the  centre  of  the  bladder,  let  the  fluid  and 
fragments  run  out,  and  attach  to  the  catheter  the  aspirator  ; 
turn  the  valve,  and  compress  and  relax  the  bulb  so  that  an 
ounce  or  more  of  fluid  is  forced  in  at  each  squeeze,  the  com- 
pression coinciding  with  expirations.  The  debris  falls  into 
a  bulb,  and  the  pumping  is  continued  until  fragments  cease 
to  pass,  whereupon  the  point  of  the  catheter  is  pushed 
against  the  floor  of  the  bladder  and  another  trial  is  made. 
If  fragments  which  cannot  gain  exit  are  felt  knocking  against 
the  tube,  withdraw  the  evacuator,  crush  again,  and  again  use 
the  aspirator.  When  no  more  debris  comes  away  and  no 
more  fragments  are  felt,  withdraw  the  tube  and  carefully  sound 
the  bladder.  Keyes  advises  the  operator  to  seek  for  a  final 
fragment  by  listening  with  a  stethoscope  while  pumping  at  the 
bulb  and  searching  the  bladder  with  the  tube.     This  opera- 


DISEASES   OF   THE    GENITOURINARY  ORGANS.      733 

tion  will  rarely  occupy  over  forty  minutes,  though  Bigelow 
has  protracted  it  for  three  hours,  the  patient  recovering. 
A  serious  complication  is  severe  bleeding,  due  to  damage 
done  with  the  instrument  or  to  the  presence  of  a  tumor 
which  easily  bleeds.  The  injection  of  moderately  hot  water 
usually  checks  hemorrhage,  but  if  bleeding  is  dangerous  in 
amount  the  operation  of  litholapaxy  should  be  abandoned, 
and  a  suprapubic  lithotomy  be  performed  instead. 

If  clogging  of  the  instrument  with  fragments  occurs, 
forcible  pushing  of  the  blades  together  repeatedly  will 
probably  amend  it ;  but  it  should  never  happen,  as  the 
occurrence  indicts  the  operator  of  carelessness  or  of  ignor- 
ance in  using  an  improper  tool.  A  lithotrite  with  a  fenes- 
trated blade  will  not  lock.  If  the  blades  become  forcibly 
and  hopelessly  locked,  make  a  perineal  section,  clear  out 
the  blades,  and  then  withdraw  the  instrument.  Forbes's 
lithotrite  is  a  very  powerful  tool. 

After-treatment. — Put  the  patient  to  bed,  apply  a  bag  of 
hot  water  to  the  hypogastrium,  and  give  him  a  hypodermatic 
injection  of  morphia  as  he  recovers  from  ether.  Give  a  hot 
hip-bath  every  night,  and  administer  every  day  liquor  potassii 
citratis  in  moderate  doses.  If  urethral  fever  occurs,  use 
quinine  and  morphia,  wash  the  bladder  several  times  daily 
with  warm  boracic-acid  solution,  and  tie  in  a  rubber  catheter. 
If  retention  occurs,  use  the  catheter.  If  cystitis  appears,  treat 
as  in  an  ordinary  case.  The  urine  ceases  to  be  bloody  in 
two  or  three  days,  and  the  patient  may  get  up  in  a  week. 

Litholapaxy  in  Male  Children. — It  was  considered  until 
quite  recently  that  a  child,  because  of  the  small  size  of  its 
bladder,  the  small  diameter  of  the  urethra,  and  the  readiness 
with  which  the  mucous  membrane  is  ruptured  by  even 
slight  violence,  was  a  bad  subject  for  crushing.  Lateral 
lithotomy  is  known  to  be  eminently  successful  when  per- 
formed   upon   children.     The  elder  Gross   did  this   opera- 


734  ^    MANUAL    01^   SURGERY. 

tion  upon  'j2  children  with  only  2  deaths.  Dr.  Keegan, 
however,  has  persuaded  the  profession  that  rapid  hthotrity 
is  perfectly  applicable  to  children :  he  shows  that  the 
bladder  of  a  child  even  less  than  two  years  of  age  is 
quite  large  enough  to  allow  the  surgeon  to  manipulate  an 
instrument,  that  the  mucous  membrane  is  in  no  danger  if 
the  operator  be  careful,  and  that  the  urethra  is  by  no  means 
so  small  as  was  supposed.  The  urinary  meatus  must  often 
be  incised,  and  after  doing  this,  Keegan  states,  there  can  be 
passed  in  a  boy  of  from  three  to  six  years  a  No.  7  or  8 
lithotrite  (English),  and  in  a  boy  of  from  eight  to  ten  years 
a  No.  10  or  even  a  No.  14.  It  is,  however,  just  to  state 
that  the  operation  is  more  delicate  than  a  like  procedure  on 
older  persons,  and  that  no  one  is  justified  in  doing  it  who 
has  not  had  considerable  experience  in  adult  cases.  Further- 
more, it  should  be  noted  that  Keegan's  mortality  by  this 
operation  has  been  4.3  per  cent.,  while  Gross's  mortality 
from  lateral  lithotomy  on  children  was  2.67  per  cent. 

Special  points  of  litJiolapaxy  on  male  children  are  as  fol- 
lows :  Use  well-fenestrated  lithotrites ;  have  a  stylet  to  punch 
out  the  fragments  blocking  the  evacuator ;  and  crush  the 
stone  to  a  fine  mass.  There  can  usually  be  employed  a  No. 
8  lithotrite  and  a  No.  8  evacuating-tube. 

Operation  for  Stone  in  Women. — If  the  stone  be  small, 
give  the  patient  ether,  place  her  in  the  lithotomy  position, 
dilate  the  urethra  with  a  uterine  dilator  until  it  admits  the 
index  finger,  and  remove  the  stone  with  the  finger,  the 
scoop,  or  the  forceps.  If  the  stone  is  found  to  be  too 
large  to  pass,  crush  it  with  a  lithrotrite  and  get  rid  of  the 
debris  by  the  evacuator.  Large  stones  (two  ounces)  may 
require  a  suprapubic  lithotomy.  Vaginal  lithotomy  is  never 
required.  If  done,  it  is  very  likely  to  leave  as  a  legacy  a 
vesico-vaginal  fistula.  In  female  children  dilate  the  urethra, 
crush  the  stone,  and  evacuate. 


DISEASES   OF   THE    GEKITOCRLVAR  Y  ORGAXS.      735 

Cystotomy. — This  term  means  the  opening  of  the  bladder, 
and  it  is  usually  applied  to  an  opening  made  for  drainage, 
for  diagnosis,  for  the  remov^al  of  stones  and  tumors,  and  for 
the  treatment  of  ulcers.  This  opening  may  be  done  by  (i)  a 
suprapubic  cut  (^as  in  suprapubic  lithotomy),  (2)  a  lateral 
perineal  cut  (as  in  lateral  lithotomy),  or  (3)  a  median  perineal 
cut  (as  in  median  lithotomy). 

Suprapubic  Cystotomy. — To  explore  the  bladder,  to 
treat  an  ulcer,  or  to  remove  a  tumor,  perform  suprapubic 
cystotomy  and  illuminate  the  interior  of  the  bladder  by  the 
rays  of  an  electric  lamp,  which  appliance  is  fastened  with 
a  mirror  to  the  forehead  of  the  operator.  The  inflation  of 
the  rectum  is  a  decided  advantage.  If  an  ulcer  is  found,  it  is 
scraped  with  a  curette  or  a  spoon.  Most  cases  of  tumor 
require  suprapubic  cystotomy.  It  is  true  that  a  small  single 
growth  at  the  vesical  neck  is  accessible  b}'  median  cyst- 
otomy, but  the  area  for  manipulation  is  ver\'  narrow  and  the 
growth  cannot  be  seen.  Every  large  growth,  all  cases  of 
multiple  tumors,  and  all  cases  of  tumor  with  great  depth  of 
perineum  or  with  enlarged  prostate  require  suprapubic  cyst- 
otomy, an  operation  which  allows  one  to  feel  and  to  see 
the  growth,  which  gives  room  for  manipulation,  and  which 
permits  thorough  exploration  of  the  entire  bladder.  The 
patient  is  put  in  the  Trendelenburg  position  (Fig.  146). 
After  opening  the  bladder  as  for  stone,  hold  the  edges  of  the 
incision  apart  by  specula  (specula  of  Keen  or  Watson)  or  by 
retractors  and  throw  in  the  electric  rays.  Growths  when 
seen  can  be  twisted  off,  a  pair  of  forceps  holding  the  base 
and  another  pair  being  used  to  twist.  Broad  growths  are 
transfixed,  ligatured,  and  severed.  Some  growths  (as  cancer) 
are  removed  piece  by  piece  with  Thompson's  forceps,  the 
base  being  scraped.  Soft  growths  are  scraped  awa}-  with  a 
curette,  a  spoon,  or  a  finger-nail.  If  bleeding  is  severe,  check 
it  by  pressure,  by  iced  water,  or  even  by  the  actual  cauter}\ 


736  A   MANUAL    OF  SURGERY. 

Median  Cystotomy. — The  same  incision  is  made  in  the 
perineal  raphe  in  median  cystotomy  as  for  median  hthot- 
omy.  A  grooved  staff  is  introduced  and  is  hooked  up  under 
the  pubes  ;  an  incision  is  made  into  the  membranous  urethra 
and  is  extended  backward  for  three-quarters  of  an  inch,  and 
a  finger  is  carried  into  the  bladder.  If  searching  for  a 
growth,  find  it  with  the  finger,  catch  it  in  Thompson  for- 
ceps, and  twist  it  off.  Soft  growths  can  be  scraped  away. 
Stop  bleeding  by  digital  pressure  or  by  injections  of  iced 
water.  If  median  cystotomy  does  not  allow  access  to  the 
tumor,  perform  suprapubic   cystotomy. 

Growths  in  the  Female  Bladder. — Dilate  the  urethra  as 
in  a  case  of  stone,  and  scrape,  twist,  pull,  or  ligature  the 
growth  away.  If  the  growth  is  large  or  if  there  are  multiple 
growths,  perform  suprapubic  cystotomy. 

XXXV.  DISEASES  AND  INJURIES  OF  THE  URE- 
THRA, PENIS,  TESTICLES,  PROSTATE,  SPER- 
MATIC CORD,  AND  TUNICA  VAGINALIS. 

Injuries  may  arise  from  traumatism  to  the  perineum  or 
the  penis,  from  cuts  and  twists  of  the  penis,  from  the  pop- 
ular "breaking"  of  a  chordee,  from  tying  strings  around 
the  organ,  from  forcing  rings  over  it,  from  the  passage  of 
instruments,  or  from  the  impaction  of  calculi.  The  writer 
saw  one  man  with  a  glass  rod  broken  off  in  the  canal,  he 
having  been  in  the  habit  of  introducing  it  at  the  dictate  of 
morbid  sexual  excitement.  A  patient  in  the  Insane  Depart- 
ment of  the  Philadelphia  Hospital  had  a  ring  around  his 
penis,  which  organ  was  lacerated  into  the  urethra.  These 
injuries  are  treated  on  general  principles. 

Perineal  Bruises. — If  the  perineum  be  bruised  without 
rupture  of  the  urethra,  the  perineum  and  scrotum  swell  and 
become  discolored ;  water  is  passed  with  difficulty  because 


DISEASES  AND   IXJURIES   OF  THE    URETHRA,  ETC.     737 

of  the  extravasation  in  the  periurethral  tissues  occluding 
more  or  less  the  canal ;  the  water  is  not  bloody ;  and  there 
are  pain  and  profound  shock.  Some  authors  designate  as 
rupture  those  cases  in  which  laceration  of  the  spongy  tissue 
occurs,  without  involvement  of  the  mucous  membrane  or 
of  the  fibrous  coat,  but  they  are  properly  contusions. 

Treatment  of  Perineal  Bruises. — Place  the  patient  in  bed 
and  establish  reaction,  and  when  reaction  is  complete  em- 
ploy opiates  for  the  relief  of  pain.  Place  lint,  wet  and  kept 
wet  with  lead-water  and  laudanum,  upon  the  perineum,  alter- 
nating every  two  hours  with  a  fifteen-minute  application  of 
the  ice-bag.  If,  notwithstanding  these  measures,  swelHng 
continues,  introduce  a  silver  catheter  (No.  12  E.),  tie  it  in, 
and  make  firm  pressure  upon  the  perineum  by  a  firmly- 
applied  T-bandage  or  by  a  crutch  braced  against  the  thighs 
or  the  foot-board  of  the  bed.  Even  when  swelling  is  slight 
retention  may  occur  from  projection  into  the  canal  of  the 
urethra  of  a  submucous  blood-clot.  Punctured  wounds  of 
the  urethra  require  ordinary  dressings.  Incised  zvounds  of  tJic 
tiretiira,  when  longitudinal,  are  closed  by  suture.  Healing  is 
rapid,  and  ill  consequences  are  not  to  be  feared.  Stricture 
does  not  follow.  When  the  wound  is  transverse,  introduce 
a  catheter,  suture  the  wound  over  the  instrument,  and  remove 
the  catheter  at  the  end  of  the  third  day.  If  a  catheter  can- 
not be  introduced,  employ  sutures,  but  at  the  first  evidence 
of  extravasation  open  the  wound,  and  if  drainage  is  not  free 
perform  an  external  perineal  urethrotomy. 

Rupture  of  the  Urethra. — By  this  term  is  meant  a  lace- 
rated or  a  contused  wound  of  the  urethra,  destroying  par- 
tial!)' or  entirely  the  integrity  of  the  canal.  A  lacerated 
wound  can  be  induced  by  fracture  of  the  cavernous  bodies 
during  erection,  the  symptoms  being  severe  hemorrhage, 
intense  pain,  retention  of  urine,  and  inability  to  pass  an 
instrument ;  infiltration  of  urine  occurs,  and  gangrene  is  a 
47 


738  A   MANUAL    OF  SURGERY. 

common  result.  The  writer  has  seen  one  case  of  rupture 
of  the  penile  urethra  due  to  a  man's  slipping  while  shaving, 
the  penis  being  caught  in  a  partially  open  drawer,  the 
drawer  being  shut  by  his  body  coming  against  it.  Rupture, 
however,  is  almost  invariably  located  in  the  perineum,  and 
it  arises  when  the  urethra  is  suddenly  and  forcibly  pressed 
against  the  ramus  of  the  pubes  by  a  blow,  by  a  kick, 
or  by  falling  astride  a  beam  or  a  fence-rail.  The  lesion  of 
urethral  rupture  consists  in  some  cases  of  laceration  of  the 
spongy  tissue  and  the  mucous  membrane,  a  cavity  being 
formed  which  communicates  with  the  canal,  and  which  fills 
with  urine  during  micturition.  In  other  cases  not  only  the 
spongy  tissue  and  the  urethral  mucous  membrane  are  rent 
asunder,  but  the  fibrous  coat  is  also  torn,  the  canal  opening 
directly  into  the  perineal  tissues,  among  which  a  huge  cavity 
forms,  that  fills  with  blood  and  later  with  clot,  urine,  and 
pus.  The  urethra  may  be  torn  entirely  across,  but  in  most 
cases  a  small  portion  at  least  of  its  circumference  is  unin- 
jured. Rupture  never  occurs  primarily  and  alone  in  the 
prostatic  urethra;  it  is  extremely  rare  in  the  membranous 
urethra  unless  due  to  pelvic  fracture ;  and  it  is  very  unusual 
in  the  penile  urethra.  The  seat  of  rupture  in  the  great 
majority  of  cases  is  in  the  region  of  the  bulb.  Very  rarely 
is  the  skin  broken. 

Symptoms. — -The  symptoms  of  rupture  of  the  urethra 
are — considerable  pain,  aggravated  by  motion,  pressure,  and 
attempts  to  pass  the  water  ;  great  shock  ;  in  some  cases  mic- 
turition is  still  possible,  blood  preceding  and  discoloring  the 
stream,  for  some  blood  usually  runs  into  the  bladder ;  reten- 
tion soon  comes  on  ;  in  a  vast  majority  of  the  cases  retention 
is  absolute  from  the  very  first,  and  it  is  due  to  the  interrup- 
tion in  the  integrity  of  the  canal  and  to  the  occlusion  of  the 
channel  by  blood-clots.  Bleeding,  which  is  usually  free,  lasts 
for  several  hours,  some  little  blood  generally  appearing  exter- 


DISEASES  AND   IXJURIES  OF  THE    URETHRA,  ETC.     739 

nally  and  much  being  retained  in  the  perineum,  inducing 
progressive  sweUing.    The  presence  of  blood  is  regarded  as 
evidence  of  urethral  rupture.    The  perineal  swelling  is  due  to 
blood  which  may  extend  under  the  fascia  to  the  penis  and 
scrotum  ;  the  swelling  soon  becomes  reddish,  purple,  or  even 
black,  and  pressure  upon  it  is  apt  to  cause  blood  to  run  from 
the  meatus.    This  swelling  enlarges  when  attempts  are  made 
to  urinate.     After  a  time,  if  the  surgeon  does   not  act,  the 
urine -fills  the  perineal  cavit\'  and  widely  infiltrates,  and  there 
ensue  gangrene,  sloughing,  and  sepsis,  life  being  endangered 
or  fistulae  being  left  as  legacies.     In  rupture  of  the  urethra 
the  course  of  the  extravasated  urine  will  often  enable  one 
to  locate  the  seat.     In  rupture  of  the  membranous  urethra, 
if  uncomplicated,  the  urine  remains  between  the  two  layers 
of  the  triangular  ligament  until  a  channel  is  opened  for  it 
by  sloughing  or  b\'  the  knife.     When  extravasation  occurs 
behind  the  posterior  layer  of  the  ligament  the  urine  finds 
its  way  to  the  perineum  in  the  neighborhood  of  the  anus. 
When  the  rupture  is  in  front  of  the  anterior  layer  the  urine, 
directed  by  the  deep  layer  of  the  superficial  fascia,  finds  its 
way   into  the  scrotum  and  up  on  the  belly,  but  does  not 
pass   into   the   thighs.     A  contusion   is   distinguished   from 
a  rupture  by  the  facts  that  in  the  former  the  perineal  swell- 
ing does  not  enlarge  on  attempting  micturition,  while  in  the 
latter  it  does ;  and  contusion  does  not  cause  urethral  hemor- 
rhage,  while    rupture   does.     A   contusion    sometimes,   but 
not   often,  prevents  the  passage  of  a   catheter ;    a   rupture 
almost  always,  but  not  invariably,  does  so.     The  mortality 
from  severe  rupture  with  extravasation  is  grave.     ^Massing 
together  all   cases,  the  mortality  is   14  per  cent.  (Kaufman). 
Treatment. — In  recent  cases  of  ruptured  urethra  the  treat- 
ment is  as  follows  :  imm.ediate  perineal  section  with  turning 
out  of  the  clot;   trimming  off  of  lacerated  edges;    finding 
the  proximal  end  of  the  urethra,  passing  a  catheter  from  the 


740  A    MANUAL    OF  SURGERY. 

meatus  into  the  bladder,  and  leaving  it  ///  situ  until  healing 
has  begun  around  it.  In  cases  with  extravasation,  lay  open 
freely  all  pockets  of  urine  and  proceed  as  above.  If  the 
proximal  end  of  the  urethra  cannot  be  found,  either  open  the 
bladder  by  Cock's  method  of  perineal  section  without  a  guide, 
cutting  toward  the  apex  of  the  prostate  gland  and  carrying  the 
incision  forward  into  the  rent,  or  perform  a  suprapubic  cyst- 
otomy with  retrograde  catheterization  ;  that  is,  push  an  instru- 
ment from  the  bladder  into  the  wound,  and  use  it  to  guide 
a  catheter  passed  from  the  meatus  into  the  bladder.  It  is 
always  well  to  attempt  to  suture  together  the  divided  ends 
of  the  canal.  The  wound  is  packed  with  iodoform  gauze,  and 
the  bowels  are  tied  up  with  opium  for  a  few  days.  Many 
surgeons  strongly  disapprove  of  the  custom  of  retaining  the 
catheter,  and  merely  stuff  the  wound  with  gauze,  the  patient 
urinating  through  the  wound  for  the  first  few  days,  after 
which  time  a  catheter  is  used.  When  the  rupture  is  in  the 
bulb  perineal  section  is  performed  to  permit  drainage,  the 
rent  is  sutured,  and  a  catheter  is  retained  as  a  support. 
Whatever  method  is  employed,  healing  will  require  from  six 
to  eight  weeks,  and  the  patient  must  ever  after  frequently 
introduce  large-sized  bougies. 

Foreign  Bodies  in  the  Urethra. — These  bodies  may  be 
calculi,  bodies  introduced  by  injury,  as  shot,  bone,  etc., 
bodies  entering  from  a  morbid  opening  into  the  rectum,  or 
bodies  introduced  from  the  meatus,  as  broken  bits  of  cathe- 
ters, straws,  pins,  etc.  The  symptoms  vary  with  the  size  and 
the  nature  of  the  body.  Sometimes  there  are  almost  no 
symptoms  ;  at  other  times  there  are  found  great  pain,  reten- 
tion of  urine,  and  hemorrhage.  Examination  is  made  by  feel- 
ing externally  with  a  finger  in  the  rectum  and  by  searching 
very  gently  with  a  sound,  taking  care  not  to  push  the  body 
back.  If  the  bladder  is  well  filled  with  water  when  the  body 
becomes  impacted,  inject  a  little  oil  into  the  meatus,  close 


DISEASES  AND   INJURIES  OF  THE    URETHRA,  ETC.    74 1 

the  lips  with  the  fingers,  and  direct  the  patient  to  forcibly 
attempt  urination,  the  surgeon  opening  the  meatus  when  the 
urethra  is  widely  distended,  the  foreign  body  being  often 
forced  out.  If  this  manoeuvre  fails,  and  the  foreign  body 
is  impacted  in  the  pendulous  urethra,  prevent  its  backward 
passage  by  at  once  tying  a  rubber  tube  around  the  penis. 
Try  to  squeeze  the  body  out,  and,  if  unsuccessful,  endeavor 
to  catch  it  with  a  wire  loop,  with  a  scoop,  or  with  the  long 
urethral  forceps.  If  these  methods  fail,  cut  down  upon  the 
body  and  remove  it,  dividing  any  existing  stricture.  If  a 
hair-pin  is  in  the  canal,  the  feet  of  the  pin  are  almost  always 
pointing  to  the  meatus  ;  to  prevent  them  catching  on  at- 
tempted withdrawal,  the  penis  must  be  squeezed  to  approxi- 
mate the  feet,  and  when  they  are  adjacent  a  part  of  a  silver 
catheter  is  slipped  over  to  retain  them  in  this  position,  when 
the  pin  can  be  extracted.  If  this  fails,  drag  the  penis  against 
the  belly,  by  rectal  touch  force  the  sharp  ends  out  through 
the  integument,  cut  one  end  off,  and  then  withdraw  the  other. 
An  ordinary  large-headed  pin  is  forced  out  in  the  same  way, 
and  when  the  head  is  turned  externally  it  is  extracted  from 
the  meatus.  If  a  lithotrite  loaded  with  fragrments  be  cau^jht 
in  the  urethra,  the  surgeon  must  perform  a  perineal  section, 
clean  and  close  the  blades,  and  withdraw  the  instrument. 

Urethritis,  or  Inflammation  of  the  Urethra. — Urethral 
inflammations  can  be  divided  into  two  classes:  (i)  Simple,  in 
which  infection  is  due  alone  to  pyogenic  cocci,  and  (2)  specific, 
in  which  the  gonococcus  is  present. 

Simple  urethritis  may  be  due  to  several  causes,  such  as 
traumatism;  great  acidity  of  the  urine;  chancre  in  the  urethra; 
contact  with  menstrual  fluid,  leucorrhoeal  discharge,  the  dis- 
charge from  malignant  disease  of  the  uterus,  ordinary  pus, 
or  acid  vaginal  discharge;  the  passage  of  instruments; 
irritant  diuretics ;  strong  injections ;  worms  in  the  rectum  ; 
and  the  passage  or  impaction  of  foreign  bodies.     A  tern- 


742  A   MANUAL    OF  SURGERY. 

porary  and  mild  urethritis  sometimes  accompanies  early 
syphilitic  eruptions.  Simple  urethritis  is  usually  less  severe 
and  prolonged  than  specific  urethritis,  though  clinically  the 
surgeon  cannot  invariably  distinguish  between  the  two  forms. 
Professor  Coplin  is  persuaded  that  the  gonococcus  is  never 
found  in  the  discharge  of  simple  urethritis.  In  the  non- 
specific inflammation  pus  is  not  always  present,  many  cases 
stopping  short  of  it  after  a  varying  period  of  catarrh,  but  any 
catarrh  can  become  purulent. 

Traumatic  Urethritis. — The  pain  in  traumatic  urethritis 
is  coincident  with  the  introduction  of  the  foreign  body.  The 
discharge,  which  may  be  bloody,  mucous,  muco-purulent,  or 
purulent,  comes  on  within  twenty-four  hours. 

Treatment. — If  the  inflammation  is  slight,  prescribe  diluent 
drinks,  paregoric,  and  a  saline.  If  severe,  put  the  patient  to 
bed,  apply  warm  fomentations  to  the  perineum,  give  diluent 
drinks,  employ  suppositories  of  opium  and  belladonna,  and 
watch  for  fever  and  other  complications. 

Gouty  Urethritis. — This  condition  first  manifests  itself  in 
the  posterior  urethra,  not  in  the  anterior,  as  does  clap.  Its 
symptoms  are — great  vesical  irritability ;  pain  on  urina- 
tion ;  discharge,  usually  scanty,  associated  with  uric  acid  in 
the  urine  or  other  symptoms  of  gout.  The  treatment  com- 
prises dieting  and  the  usual  remedies  for  gout.  Purgatives 
are  giv^en  freely,  and  full  doses  of  colchicum,  piperazine,  or 
the  alkalies  ;  hot  baths,  low  diet,  diluent  drinks,  and  diapho- 
retics are  indicated.  A  chronic  discharge  from  the  prostatic 
region  is  apt  to  linger;  for  this  there  is  nothing  better  than 
the  usual  gouty  remedies  and  saline  waters  with  copaiba, 
cubebs,  or  sandalwood  oil. 

Eczematous  Urethritis. — Berkeley  Hill  states  that  this 
disease  is  very  obstinate,  is  probably  associated  with  gout, 
and  is  met  with  in  adults  of  full  habit  or  who  are  beer- 
drinkers  and  who  have  eczema  of  the  surface  of  the  body. 


DISEASES  AXD   INJURIES  OF  THE    URETHRA,  ETC.     743 

He  states  also  that  the  glans  penis  near  the  meatus  is  red 
and  tender,  and  that  the  interior  of  the  urethra  is  in  the 
same  condition.  Pain  is  constant,  and  it  is  aggravated  on 
micturition.  The  discharge  is  scanty.  The  treatment  com- 
prises injections  of  cold  water  or  irrigation  with  ice-water, 
and  internally  the  administration  of  arsenic  with  the  alkalies. 

Tubercular  urethritis  is  due  to  a  tubercular  ulcer  which 
is  most  apt  to  be  seated  near  the  vesical  neck.  There  is  a 
little  pain  on  micturition,  but  there  is  intense  pain  at  one 
spot  on  passing  a  bougie.  The  discharge  is  slight  and  at 
times  bloody.  The  bladder  is  ver)-  irritable,  and  severe 
cystitis  arises  and  persists.  The  treatment  includes  fresh 
air,  sunlight,  warmth,  good  food,  and  cod-liver  oil.  The 
bladder  is  w^ashed  out  once  a  day  with  boracic-acid  solution, 
but  after  a  time  the  surgeon  wnll  be  forced  to  drain  by  peri- 
neal or  suprapubic  cystotomy. 

Gonorrhoea  (Clap  ;  Specific  Urethritis  ;  Tripper  ;  Venereal 
Catarrh). — Gonorrhoea  is  an  acute  inflammation  of  the  genital 
mucous  membrane,  of  venereal  origin,  due  to  the  deposition 
and  multiplication  of  gonococci  in  the  cells  of  the  meiji- 
brane  and  a  mixed  infection  with  the  cocci  of  suppuration. 
In  the  male,  clap  begins  within  the  meatus  and  fossa  navicu- 
laris  and  extends  backward  throughout  the  length  of  the 
urethra.  The  mucous  membrane  swells  and  becomes  hyper- 
^mic,  and  there  is  a  discharge,  first  of  mucus  and  serum, 
and  then  of  pus.  In  severe  cases  the  discharge  is  bloody 
(black  gonorrhcea).  For  a  week  or  more  the  inflammation 
increases,  then  becomes  stationary  for  a  time,  and  then 
declines,  the  discharge  growing  less  profuse  and  thinner, 
a  w^atery  discharge  lasting  for  some  little  time.  During  the 
acute  stage  the  entire  penis  swells  and  the  corpus  spongiosum 
becomes  infiltrated  with  inflammatory  exudate.  CJiordee  is 
a  painful  erection  in  which  the  penis  bends  because  of  the 
rigid  infiltration  of  the  corpus  spongiosum. 


744  A   MANUAL    OF  SURGERY. 

SyniptoDis  of  Aaitc  Inflammatoiy  Gonorrlicca. — The  period 
of  incubation  is  from  a  few  hours  to  two  weeks.  The  patient 
notices  on  arising  a  drop  of  thin  fluid  which  glues  together 
the  hps  of  the  meatus,  and  he  feels  some  pain  on  urination. 
The  meatus  is  red  and  swollen.  Within  forty-eight  hours 
the  first  stage,  or  the  stage  of  increase,  becomes  established. 
The  meatus  is  now  red,  swollen,  and  everted  (fish-mouth 
meatus) ;  micturition  causes  severe  pain  (ardor  urinae) ; 
chordee  occurs,  especially  when  the  patient  is  warm  in  bed ; 
there  is  frequent  micturition  with  tenesmus,  and  a  profuse 
discharge  which  is  yellow,  greenish,  or  even  bloody.  The 
complications  of  this  stage  are  balanitis  (inflammation  of  the 
mucous  membrane  of  the  glans  penis),  balano-postliitis  (in- 
flammation of  the  surfece  of  the  glans  and  the  mucous 
membrane  of  the  ^r^ipwco),  phimosis  (thickening  and  contrac- 
tion of  the  foreskin  so  that  the  glans  cannot  be  uncovered), 
and  parapliiinosis  (catching  and  fixation  of  the  retracted 
prepuce  behind  the  corona  glandis).  In  the  second  or  sta- 
tionary stage,  which  lasts  from  the  end  of  the  first  week  to 
the  end  of  the  second  (White),  the  acute  symptoms  of  the 
first  stage  continue.  The  complications  of  this  stage  are 
periurethral  abscess,  lymphangitis,  solitary  and  painful  bubo 
of  the  groin  which  may  suppurate,  inflammation  of  Cowper's 
glands,  inflammation  of  the  prostate  or  of  the  bladder,  and 
gonorrhoeal  ophthalmia.  In  the  third  or  subsiding  stage  the 
symptoms  gradually  abate,  the  discharge  becoming  scantier 
and  thinner  and  finally  drying  up.  This  stage  is  of  uncer- 
tain duration,  and  in  it  there  may  occur  epididymitis^  or 
inflammation  of  the  epididymis. 

Subacute  or  catarrhal  g-onorrhoea  develops  in  men  who 
have  previously  had  gonorrhcea,  as  a  result  of  prolonged  or 
repeated  coition  or  of  contact  with  menstrual  fluid  or  leucor- 
rhoeal  discharge.  There  is  profuse  muco-purulent  discharge, 
very  little  pain    on  micturition,  rarely  chordee  or  marked 


DISEASES  AKD   IXJURIES  OF  THE    URETHRA,  ETC.     745 

irritability  of  the  bladder.  In  this  condition,  according  to 
White,  gonorrhoeal  rheumatism  (p.  412)  is  most  apt  to  occur. 

Irritative  or  Abortive  Gonorrhoea. — In  this  disease  the 
symptoms,  which  are  identical  with  those  of  beginning  clap, 
do  not  increase,  but  are  apt  to  disappear  within  ten  days. 

Chronic  Urethral  Discharges. — Chronic  urethral  catarrh, 
which  may  follow  gonorrhoea,  is  characterized  by  the  occa- 
sional presence  of  a  drop  of  clear  tenacious  liquid.  This 
discharge  becomes  more  profuse  as  a  result  of  sexual  ex- 
citement or  the  abuse  of  alcohol. 

Chronic  Gonorrhoea. — The  persistence  of  a  small  amount 
of  milky  discharge,  because  of  localization  of  inflammation 
in  one  spot  or  the  production  of  a  granular  patch  or  a  super- 
ficial ulcer,  characterizes  chronic  gonorrhoea.  There  is  some 
scalding  on  urination  ;  erections  produce  aching  pain  ;  there 
are  pain  in  the  back  and  redness  and  swelling  of  the  meatus. 
All  the  symptoms  are  intensified  by  sexual  excitement,  by 
coitus,  by  violent  exercise,  or  by  alcoholic  excess. 

Gleet. — In  gleet  the  lips  of  the  meatus  are  stuck  together 
in  the  morning,  and  squeezing  them  discloses  a  drop  of 
opalescent  muco-purulent  fluid.  During  the  day  the  dis- 
charge is  rarely  found.  There  are  frequency  of  micturition, 
pains  in  the  back,  and  dribbling  of  urine,  and  a  bougie  will 
find  a  stricture  of  large  calibre.  A  discharge  may  be  main- 
tained by  chronic  prostatitis.  In  this  condition  there  are  fre- 
quency of  micturition  ;  a  sense  of  weight  or  dull  pain  in  the 
perineum  ;  diminished  projectile  force  of  the  stream  of  urine  ; 
the  first  portion  of  urine,  if  collected  in  a  glass,  is  more 
turbid  than  the  second  portion  (Ultzmann) ;  the  sediment 
consists  of  "prostatic  epithelium,  muco-pus,  and  mucous 
shreds  "  (White) ;  there  is  often  a  tendency  to  sexual  excite- 
ment and  premature  emission. 

Treatment  of  Acute  Gonorrhcca. — Abortive  treatment  should 
be  tried  if  tlie  case  is  seen  early.     The  writer's  plan  is  to 


746  A   MANUAL    OF  SURGERY. 

cleanse  the  urethra  several  times  a  day  by  injecting  peroxide 
of  hydrogen  (15-volume  solution  diluted  with  an  equal 
amount  of  water).  After  each  injection  of  peroxide  intro- 
duce oil  of  cinnamon  into  the  urethra  by  means  of  a  metal- 
nozzled  atomizer  or  even  an  ordinary  syringe  (the  oil  is 
mixed  with  benzoinol,  three  solutions  being  used,  the  strength 
being  respectively  i  drop,  2  drops,  and  3  drops  to  the 
ounce).  The  mild  solution  of  oil  of  cinnamon  is  used  the 
first  day,  the  2-drop  solution  the  second  day,  the  3-drop 
solution  the  third  day  if  the  urethra  will  tolerate  it.^  Other 
abortive  methods  are  the  use  of  hot  retro-injections  of  cor- 
rosive-sublimate solution  (1:20,000),  two  pints  being  run 
through  the  urethra  once  a  day,  strong  injections  of  nitrate 
of  silver  or  of  tannin,  scraping  the  meatus  and  the  urethra 
adjacent  with  cotton,  and  injecting  15  drops  of  a  3  per 
cent,  solution  of  nitrate  of  silver.  If  in  seventy-two  hours 
the  symptoms  are  not  greatly  improved,  abortive  treatment 
should  be  abandoned  (Horwitz).  In  treating  a  developed 
case,  order  plain,  non-stimulating  diet  and  the  avoidance 
of  alcohol,  sexual  excitement,  wet,  and  violent  or  prolonged 
exercise.  The  patient  should  sleep  under  light  covers  and 
drink  much  water  daily  (Seltzer,  Apollinaris,  or  ordinary 
water  containing  bicarbonate  of  soda).  If  the  foreskin  is  long, 
the  discharge  should  be  caught  by  placing  bits  of  absorbent 
cotton  over  the  meatus  and  within  the  prepuce.  If  the  fore- 
skin is  short,  cut  a  small  opening  in  a  square  piece  of  old 
linen,  slip  this  linen  over  the  glans,  catch  it  back  of  the 
corona,  and  bring  the  ends  forward  with  the  prepuce.  If 
the  glans  is  completely  naked,  pin  an  old  stocking-foot  upon 
the  undershirt  and  in  it  hang  the  penis. 

Irritative  gonoT'rhcea   will    subside   in   a  few   days.     The 
above  treatment  should  be  applied,  and  the  urethra  should 
be  washed  out  several  times  daily  with  peroxide  of  hydrogen. 
"^  Medical  News,  Oct.  21,  1893. 


DISEASES  AND   INJURIES   OF   THE   URETHRA,  ETC.    747 

In  catarrhal goriorrhcea  at  once  order  injections  (i  grain  to  the 
ounce  of  sulphate  of  zinc;  or  zinci  sulphas  gr.  viij,  plumbi 
acetas  gr.  xv,  water  5viij ;  or  gr.  v  of  sulphocarbolate  of  zinc 
to  5J  of  water;  or  White's  prescription  of  oj  each  of  acetate  of 
zinc  and  tannic  acid,  3iij  of  boric  acid,  3vj  of  liq.  hydrogen, 
peroxid.).    Use  for  injecting  a  blunt-pointed  hard-rubber  syr- 
inge of  a  capacity  of  three  drachms.     Let  the  patient  sit  on  a 
chair,   his    buttocks    hanging  over   the    edge ;    throw   in   a 
syringeful  and  let  it  at  once  run  out ;  throw  in  another  syr- 
ingeful  and  hold  it  in  from  three  to  five  minutes.     In  acute 
gonorrJicea  order  two  capsules  three  times  a  da}',  each  cap- 
sule containing   5   grains  of  salol,  5   grains  of  oleoresin  of 
cubebs,    10   grains   of  balsam   of  copaiba,   and    i    grain   of 
pepsin.    After  the  patient  micturates  he  should  employ  a  mild 
astringent  injection.     If  an  astringent  injection  causes  much 
pain,  use  a  sedative  injection — 3ij  of  boracic  acid,  gr.  viij  of 
aqueous  extract  of  opium,  and  Sviij  of  liquor  plumbi   sub- 
acetatis  dilutus.     As  the  inflammation  subsides  increase  the 
strength  of  the  injection.     A  good  plan  is  to  order  an  eight- 
ounce  bottle   and   eight  half-grain  powders  of  sulphate  of 
zinc.     Direct  the   patient  to   fill   the   bottle   with   water,  in 
which  one  powder  is  dissolved ;  when  this  is  used  dissolve 
two  powders  in  a  bottleful  of  water,  and  so  progressively 
increase  the  strength.     When  the  discharge  ceases  stop  the 
injections  gradually.     Whenever  a  syringeful  is  taken  from 
the  bottle  a  syringeful  of  water  is  put  into  the  bottle,  and 
thus  pure  water  is  soon  obtained,  at  which  point  injection 
is  discontinued. 

Ardor  tirincB  is  relieved  by  urinating  while  the  penis  lies 
in  hot  water  and  b\'  administering  an  alkaline  diuretic. 
Chordce  requires  a  bowel- movement  in  the  evening  and 
sleeping  in  a  cool  room,  under  light  covers,  and  on  a  hard 
mattress ;  bromide  is  given  several  times  daily,  and  a  con- 
siderable dose  is  given  at  night ;  it  may  be  necessary  to  use 


748  A   MANUAL    OF  SURGERY. 

suppositories  of  opium  and  camphor  or  to  give  hyoscine. 
BaliDiitis  requires  frequent  washing  with  warm  water,  drying 
with  cotton,  and  dusting  with  borated  talc  or  with  boric  acid 
and  subnitrate  of  bismuth  (i  :  6).  Balano-posthitis  requires 
lead-water  and  laudanum  and  injections  of  black  wash  under 
the  prepuce  until  oedema  of  the  foreskin  subsides,  and  then 
cleanliness  externally  and  a  powder.  PJiiniosis  requires  soak- 
ing the  penis  in  hot  water,  injections  beneath  the  foreskin  of 
hot  water,  followed  by  black  wash  and  lead-water  and  lauda- 
num externally.  If  this  fails,  circumcise.  For  paraphimosis, 
grasp  the  head  of  the  penis  with  the  left  hand,  squeeze  the 
blood  out,  and  try  to  push  the  head  back  while  with  the 
right  hand  effort  is  made  as  if  to  lift  the  individual  by  his 
penis.  If  this  fails,  cut  the  collar  on  the  dorsum  with  scissors. 
Bubo  requires  iodine,  blue  ointment,  a  spica  bandage,  and  rest. 
If  a  bubo  suppurates,  it  must  be  opened.  Acute  prostatitis 
and  cystitis  require  confinement  to  bed,  a  milk  diet,  the  use  of 
alkaline  diuretics,  hot  sand-bags  to  the  perineum  and  hypo- 
gastrium,  suppositories  of  opium  and  belladonna,  leeching 
the  perineum,  and  the  discontinuance  of  the  balsams  and 
injections.  Abscess  of  the  prostate  requires  instant  opening. 
In  retention  of  urine  the  patient  should  try  to  pass  the  urine 
while  in  a  hot  bath  ;  if  this  fails,  use  a  soft  catheter.  After 
relieving  the  bladder  put  the  patient  to  bed  and  use  hot  sand- 
bags as  for  prostatitis.  Chronic  prostatitis  requires  cold  hip- 
baths, cold-water  enemata,  deep  urethral  injections,  plain  diet, 
avoidance  of  alcohol  and  over-exertion,  counter-irritation  of 
the  perineum,  and  the  relief  of  stricture  or  phimosis.  In 
epididymitis,  put  the  patient  to  bed,  stop  injections,  shave 
the  hair  from  the  groin  and  leech  over  the  cord,  elevate 
the  testicles,  keep  the  parts  covered  with  lint  wet  with 
lead-water  and  laudanum,  and  from  time  to  time  apply 
an  ice-bag.  Give  a  cathartic,  a  fever-mixture,  and  suitable 
doses  of  bromide  of  potash  and  morphia.    When  tenderness 


ERRATUM:  page  749,  line  17,  for  80  grains,  read  3^  grains. 


ofill  ^CM 


:M-jTAHJI3" 


DISEASES  AND   INJURIES   OF   THE   URETHRA,  ETC.     749 

subsides  strap  the  testicle.  In  gonorrhceal  opJithalinia,  place 
a  watch-crystal  over  the  unaffected  eye,  put  the  patient  in 
a  darkened  room,  wash  out  the  affected  eye  often  with  hot 
boracic-acid  solution,  keep  the  pupil  dilated  with  atropine, 
leech  the  temple,  give  purgatives,  and  employ  hot  mustard 
foot-baths.     Always  send  for  an  ophthalmologist. 

Treatment  of  Chronic  GonorrJicea. — In  chronic  gonorrhoea, 
try  to  locate  any  existing  granular  or  ulcerated  patch  with 
a  bulbous  bougie.  When  the  point  is  discovered  apply  to  it, 
by  a  deep  urethral  syringe,  a  few  drops  of  a  2  per  cent,  solu- 
tion of  nitrate  of  silver.  The  strength  of  the  silver  solution 
can  gradually  be  increased,  or  other  solutions  can  be  substi- 
tuted (sulphate  of  copper  or  sulphocarbolate  of  zinc).  Pass 
a  large  bougie  every  other  day.  Copious  retro-irrigation 
with  hot  solutions  of  corrosive  sublimate  (1:20,000)  does 
good.  Horwitz  injects  into  the  bladder  once  a  day  a  pint 
of  water  containing  80  grains  of  permanganate  of  potash, 
and  the  patient  voids  it  by  an  act  of  micturition.  The  treat- 
ment of  gleet  is  the  same  as  that  of  stricture. 

Gonorrhoea  in  the  female  may  affect  the  vulva,  the 
vagina,  the  urethra,  or  the  uterus.  The  treatment  for  vulvitis 
is  to  place  the  patient  upon  a  low  diet  and  put  her  at  rest 
with  the  pelvis  elevated ;  every  two  or  three  hours  spray  the 
parts  with  peroxide  of  hydrogen,  dry  them  with  absorbent 
cotton,  and  dust  them  with  equal  parts  of  starch  and  oxide 
of  zinc.  In  severe  cases  purge,  use  hot  baths,  apply  lead- 
water  and  laudanum  locally  or  paint  the  vulva  with  silver 
solution  (gr.  xl  to  5J),  and  leech  the  groins.  If  the  vulvo- 
vaginal gland  suppurates,  open  it.  For  vaginitis,  follow  the 
same  general  directions.  Syringe  out  the  vagina  every  two 
hours,  first  with  Oj  of  hot  solution  of  bicarbonate  of  soda,  next 
with  Oj  of  hot  water,  and  finally  with  Oj  of  astringent  solu- 
tion (a  teaspoonful  of  lead  acetate,  a  teaspoonful  of  zinc  sul- 
phate, a  teaspoonful  of  alum,  or  four  teaspoonfuls  of  tannin 


750  A   MANUAL    OF  SURGERY. 

to  the  pint  of  hot  water)  (White).  Peroxide  of  hydrogen 
followed  by  oil  of  cinnamon  does  good.  As  the  attack  sub- 
sides use  vaginal  suppositories  each  containing  gr.  v  of  tannic 
acid.  For  iiretJwitis,  use  astringent  injections  locally  and 
copaiba  and  cubebs  by  the  mouth.  In  chronic  cases,  use 
strong  solutions  of  silver  nitrate.  For  uterine  gonorrhoea^ 
observe  the  same  general  management.  Swab  out  the  uterus 
with  tincture  of  iodine ;  use  tampons  of  iodoform  gauze  and 
injections  of  peroxide  of  hydrogen  and  oil  of  cinnamon. 

Stricture  of  the  urethra,  or  narrowing  of  the  urethral 
calibre,  is  divided  into  inflammatory,  spasmodic,  and  organic, 
hiflammatory  or  congestive  stricture  is  not  a  stricture,  but  is 
an  inflammatory  swelling  of  the  mucous  membrane.  Spas- 
modic stricture  does  not  exist  alone,  but  complicates  organic 
stricture,  a  hyperaesthetic  urethra,  or  an  inflamed  bladder. 
Organic  stricture  is  a  fibrous  narrowing  of  the  urethra,  due, 
as  a  rule,  to  chronic  gonorrhoeal  inflammation  or  to  trau- 
matism. Traumatic  strictures  occur  in  the  bulbous  or  mem- 
branous urethra ;  gonorrhoeal  strictures  occur  in  the  penile, 
bulbous,  or  n^embranous  urethra.  Stricture  nev^er  forms  in 
the  prostatic  urethra.  The  more  fibrous  a  stricture  is,  the 
more  it  narrows  the  urethra  and  the  less  dilatable  it  is.  A 
stricture  may  be  annular  (forming  a  ring  around  the  urethra), 
tubular  (surrounding  the  urethra  for  a  considerable  distance), 
or  bridle  (when  a  band  crosses  the  urethra  from  wall  to  wall). 
The  nearer  a  stricture  is  to  the  meatus,  the  more  fibrous  it  is. 

Results  of  Stricture. — The  urethra  back  of  the  stricture 
dilates,  a  pouch  forms,  drops  of  urine  collect  and  decompose, 
and  a  chronic  inflammation  results  in  the  mucous  membrane 
or  the  parts  adjacent,  which  inflammation  may  go  on  to 
ulceration  or  to  periurethral  abscess.  A  urinary  fistula  results 
from  the  opening  of  a  periurethral  abscess.  In  stricture  the 
stream  of  water  is  small,  twisted,  often  forked,  and  it  dribbles 
long  after  the  conclusion  of  micturition.     A  chronic  dis- 


DISEASES  AND   INJURIES  OF  THE    URETHRA,  ETC.     75 1 

charge  is  apt  to  exist,  varying  in  amount.  Retention  of 
urine  may  occur,  not  from  obliteration  of  the  tube  by  the 
growth  of  the  stricture,  but  by  swelling  in  the  neighborhood 
of  the  stricture,  due  to  some  complication  (cold,  wet,  venereal 
excitement,  the  use  of  alcohol,  over-exertion,  etc.).  Spasm  of 
the  muscles  results,  and  contact  of  the  urine  increases  the 
spasm  and  closes  the  urethra.  Spasm  may  exist  in  the  urethra 
itself  and  in  the  muscles  of  the  neck  of  the  bladder,  but  is 
only  a- temporary  condition.  In  old  strictures  the  bladder  is 
hypertrophied  and  often  fasciculated,  and  is  very  liable  to 
cystitis.  The  diagnosis  of  stricture  and  of  its  location  is 
made  by  the  use  of  exploratory  bougies. 

Treatment  of  Stricture. — Strictures  of  large  calibre  in  the 
deep  urethra  require  gradual  dilatation  with  conical  steel 
bougies.  K  bougie  is  introduced  every  third  or  fourth 
day,  the  size  being  gradually  increased.  Never  anoint  a 
bougie  with  cosmoline,  as  it  may  become  a  nucleus  for  a 
stone  in  the  bladder ;  use  oil  or  glycerin.  If  the  meatus  is 
too  small  to  admit  a  full-sized  bougie,  cut  it  with  a  knife. 
Strictures  of  large  calibre  in  the  pendulous  urethra,  if  elastic, 
are  treated  by  gradual  dilatation  ;  if  fibrous  and  contractile, 
by  internal  urethrotomy.  In  performing  internal  urethrotomy, 
prepare  the  patient  carefully ;  for  several  days  before  the 
operation  give  salol  and  boracic  acid  by  the  mouth,  and 
wash  out  the  bladder  repeatedly  with  boracic-acid  solution. 
Be  thoroughly  aseptic.  Before  cutting  irrigate  the  urethra 
with  corrosive  sublimate  (i  :  5000),  and  after  cutting  irrigate 
again  and  tie  in  a  rubber  catheter.  These  precautions  will 
prevent  urethral  fever.  In  cutting,  insert  Gross's  urethrotome 
back  of  the  stricture,  spring  out  the  blade,  cut  the  stricture 
on  the  roof  of  the  urethra,  close  the  blade,  withdraw  the 
instrument,  and  introduce  a  full-sized  bougie. 

Strictures  of  the  meatus  require  incision  with  a  knife 
and  the  use  of  a  meatus  bougie  until  healing  is  complete. 


752  A    MANUAL    OF  SURGERY. 

Strictures  of  small  calibre  in  front  of  the  membranous 
urethra  require  gradual  dilatation  and,  if  this  fails,  internal 
urethrotomy  or  divulsion.  For  divulsion  the  patient  is  pre- 
pared as  for  internal  urethrotomy.  The  divulsor  of  Gross 
or  of  Sir  Henry  Thompson  is  introduced,  the  blades  are 
separated,  the  instrument  is  withdrawn,  a  large  bougie  is 
passed,  and  a  catheter  is  tied  in  the  bladder.  Strictures  of 
small  calibre  in  the  deep  urethra  require  gradual  dilatation  ; 
if  this  fails,  employ  external  urethrotomy.  In  strictures  of 
the  deep  urethra,  if  only  a  filiform  bougie  can  be  introduced, 
the  bougie  can  be  left  in  place  and  in  a  day  or  two  another 
can  be  slipped  in  beside  it,  until  in  a  few  days  the  channel  is 
permeable  by  a  metal  bougie.  A  tunnelled  catheter  can  be 
slipped  over  the  bougie,  both  be  withdrawn,  and  a  metal 
bougie  be  passed.  A  tunnelled  and  grooved  staff  can  be 
carried  in  over  the  bougie  and  external  urethrotomy  be  per- 
formed. Thompson's  dilator  can  be  carried  over  the  bougie 
and  the  stricture  be  divulsed.  Maisonneuve's  urethrotome 
can  be  carried  over  the  bougie  and  internal  urethrotomy  be 
performed  (White  mentions  four  of  these  plans,  but  disap- 
proves of  divulsion).  In  impassable  stricture  of  the  deep 
urethra,  perform  external  perineal  urethrotomy  without  a 
guide  (the  operation  of  Cock  or  of  Wheelhouse). 

Epispadias  is  a  congenital  cleft  in  the  corpora  cavernosa, 
the  roof  of  the  urethra  being  absent. 

Hypospadias  is  a  congenital  cleft  on  the  floor  of  the 
urethra,  this  channel  being  a  gutter  instead  of  a  canal. 

Chancroid  (Soft  Chancre ;  the  Local  Venereal  Sore). — A 
chancroid  appears  soon  after  intercourse,  usually  within  five 
days,  always  within  ten  days.  It  is  first  manifested  by  a 
pustule  which  ruptures  and  discloses  an  ulcer.  This  ulcer 
has  sharply-defined  and  undermined  margins ;  it  looks 
"punched  out;"  the  base  is  gray  and  sloughy;  the  dis- 
charge is  profuse,  purulent,  foul,  and  auto-inoculable,  and 


DISEASES  AND   INJURIES   OF   THE    URETHRA,  ETC.     753 

causes  fresh  chancroids  by  flowing  over  the  parts.  The  area 
around  a  chancroid  is  red  and  inflamed,  and  considerable 
pain  is  apt  to  be  complained  of.  The  original  chancroid 
spreads  and  new  sores  appear.  The  edge  of  a  chancroid  is 
not  indurated  unless  caustics  have  been  used  or  there  is 
mixed  infection  with  syphilis.  Inflammatory  induration  fades 
gradually  into  the  tissues,  but  the  induration  of  a  hard 
chancre  is  sharply  defined.  When  a  chancroid  after  a  time 
displays  marked  and  sharply-outlined  induration,  it  means  a 
mixed  infection  of  chancroid  and  syphilis.  Chancroids  are 
not  followed  by  constitutional  symptoms,  but  are  apt  to  be 
accompanied  by  painful  inflammatory  buboes  which  are  prone 
to  suppurate.  When  inflammation  in  chancroids  is  high  a 
rapidly  destructive  ulceration  known  as  phagedena  may  arise. 
Treatment. — Ordinary  cases  of  chancroids  are  treated  by 
spraying  with  peroxide  of  hydrogen,  drying  with  cotton, 
touching  each  sore  first  with  pure  carbolic  acid  and  then 
with  pure  nitric  acid,  and  dusting  with  iodoform  or  with 
calomel.  Every  few  hours  after  this  application  the  patient 
soaks  the  penis  in  hot  salt  water  (a  teaspoonful  to  half  a 
pint),  sprays  the  sores  with  peroxide  of  hydrogen,  dries  with 
cotton,  and  dusts  with  iodoform  or  with  calomel.  As  soon 
as  granulation  begins,  dress  with  i  part  of  ointment  of  nitrate 
of  mercury  to  7  parts  of  cosmoline.  Mild  cases  do  well 
without  cauterizing,  peroxide  of  hydrogen  being  frequently 
used  and  a  drying  powder  being  employed.  In  chancroids 
with  phimosis,  slit  up  the  foreskin,  burn  the  edges  of  the 
wound  with  pure  carbolic  acid,  and  treat  the  sore  by 
cauterization.  A  set  circumcision  often  fails  because  of 
infection  of  the  stitch-holes.  Phagedena  requires  the  in- 
ternal use  of  iron,  quinine,  and  milk  punch,  and  the  local 
use  of  powerful  caustics  (bromine  or  nitric  acid)  or  even 
of  the  actual  cautery.  In  some  cases  continuous  antiseptic 
irrigation  is  valuable.     When  a  bubo  first  begins,  order  rest, 

48 


754  ^    MANUAL    OF  SURGERY. 

apply  iodine  and  ichthyol,  and  make  pressure  by  a  spica 
bandage  of  the  groin.  If  pus  forms,  incise,  curette,  cauter- 
ize with  pure  carboHc  acid,  cut  away  hopelessly  infiltrated 
skin,  and  pack  the  wound  with  iodoform  gauze. 

PhirQosis  is  a  condition  of  the  prepuce  that  renders  retrac- 
tion over  the  glans  impossible.  It  is  usually  congenital,  but 
it  may  arise  from  inflammation.  Congenital  phimosis  causes 
retention  of  sebaceous  matter,  which  decomposes  and  lights 
up  inflammation.  The  prepuce  is  apt  to  grow  fast  to  the 
glans.  Congenital  phimosis  may  induce  irritability  of  the 
bladder,  incontinence  of  urine,  prolapse  of 
the  rectum,  and  various  nervous  symptoms. 
The  treatment  is  circumcision.  Grasp  the 
foreskin  and  the  mucous  membrane  with 
two  forceps,  draw  them  forward,  catch  the 
iorSmpVet7d^('Esrarch  skiu  (at  thc  point  it  is  desired  to  cut)  hori- 
and  Kowaizig).  zoutally  between  the  handles  of  a  pair  of 

scissors,  and  cut  off  the  redundant  prepuce.  Retrench  the 
excess  of  mucous  membrane  by  cutting  around  with  scissors 
one-quarter  of  an  inch  from  the  glans,  stitch  the  skin  to  the 
mucous  membrane,  and  dress  antiseptically  (Fig.  i/i). 

Fracture  of  the  penis,  which  is  a  laceration  of  the  cav- 
ernous bodies  with  extravasation  of  blood,  occurs  occasion- 
ally during  coition.  The  treatment  requires  cold  and  band- 
aging to  arrest  bleeding,  and  occasionally  incisions  to  let 
out  clot. 

Gangrene  of  the  penis  arises  from  phagedena,  from  tying 
constricting  bands  around  the  organ,  from  fracture  with 
excessive  hemorrhage,  and  from  paraphimosis.  If  extensive, 
it  requires  amputation. 

Cancer  of  the  penis  is  commonest  in  persons  with  phi- 
mosis. In  a  limited  epithelioma  of  the  foreskin  circumcision 
is  employed ;  if  cancer  affects  the  glans,  amputation  is  re- 
quired. 


DISEASES  AND   INJURIES   OF   THE   URETHRA,  ETC.    755 

AniDutation  of  the  Penis. — Ricord  advises  cutting-  off  the 
organ  with  a  single  stroke  of  the  knife,  making  four  shts  in 
the  mucous  membrane  of  the  urethra,  and  stitching  each  of 
these  .flaps  to  the  skin.  Treves  spHts  the  skin  of  the  scrotum 
along  the  raphe,  separates  the  halves  of  the  scrotum  down 
to  the  corpus  spongiosum,  passes  a  metal  catheter  down  to 
the  triangular  ligament,  inserts  a  knife  between  the  corpus 
spongiosum  and  the  corpora  cavernosa,  withdraws  the  cathe- 
ter, cuts  the  urethra  across,  detaches  the  urethra  from  the 
penis  back  to  the  triangular  ligament,  cuts  around  the  root 
of  the  penis,  divides  the  suspensory  ligament,  detaches  each 
crus  from  the  pubes,  slits  up  the  corpus  spongiosum  half 
an  inch,  stitches  its  edges  to  the  rear  end  of  the  scrotal 
incision,  introduces  a  drainage-tube,  ligates  the  vessels,  and 
sutures  the  wound. 

Hypertrophy  of  the  prostate  gland  is  a  senile  change 
occurring  only  after  the  age  of  fifty,  and  being  most  apt  to 
occur  after  the  age  of  sixty.  All  the  lobes  may  be  enlarged 
equally,  all  may  be  enlarged  but  unequally,  or  only  one  lobe 
may  be  enlarged.  Prostatic  hypertrophy  causes  narrowing 
and  lengthening  of  the  urethra,  and  gives  this  tube  a  tor- 
tuous course.  The  opening  of  the  urethra  into  the  bladder 
is  pushed  to  a  higher  level,  and  there  forms  behind  it  a  pouch 
in  which  urine  collects.  This  urine,  which  is  known  as 
residual  urine,  may  collect  in  large  quantity ;  it  cannot  be 
voluntarily  expelled,  and  it  is  apt  to  decompose,  producing 
cystitis.  The  bladder  enlarges,  thickens,  and  becomes  fas- 
ciculated, micturition  becoming  very  difficult  and  sometimes 
impossible.  An  enlarged  middle  lobe  will  effectually  block 
the  urine  until  the  bladder  becomes  greatly  distended.  The 
ureters  distend,  so  do  the  renal  pelves  and  calyces,  and  surgi- 
cal kidney  may  develop. 

Symptoms. — In  80  per  cent,  of  all  cases  there  is  only  slight 
inconvenience.    The  stream  of  urine  is  slow  to  start  and  falls 


756  A    MANUAL    OF  SURGERY. 

feebly  from  the  end  of  the  penis.  The  last  drops  fall  entirely 
without  control,  and  there  are  occasional  episodes  of  noc- 
turnal frequency  of  micturition.  In  20  per  cent,  of  all  cases 
the  bladder  cannot  entirely  be  emptied  and  residual  urine 
collects  in  the  bladder.  Frequency  of  micturition  comes  on, 
particularly  at  night ;  the  patient  has  to  get  up  often ;  the 
bladder  never  feels  empty  ;  and  cystitis  is  apt  to  arise.  The 
urine,  at  first  acid  and  clear,  becomes  neutral  and  cloudy,  and 
finally  ammoniacal  and  turbid,  and  contains  bacteria,  muco- 
pus,  precipitates  of  phosphate,  and  blood.  Above  the  pubes 
there  is  aching  pain  soon  spreading  to  the  perineum,  which 
pain  is  increased  when  the  bladder  is  distended  and  during 
micturition.  The  rectum  becomes  irritable,  and  piles  form 
or  prolapse  of  the  mucous  membrane  occurs.  Retention  of 
urine  may  take  place.  The  bladder  becomes  thin  and  dis- 
tended or  hypertrophied, 'rigid,  and  fasciculated.  In  rare  cases 
true  incontinence  is  caused  by  the  median  lobe  growing  toward 
the  neck  of  the  bladder  and  preventing  closure.  The  health 
breaks  down  because  of  pain,  restless  nights,  indigestion,  and 
disorder  of  the  bowels.  The  kidneys  may  become  involved 
(inflammation  of  the  pelves  or  calyces,  or  surgical  kidney) 
and  suppression  may  occur.  Calculi  may  form  in  the  blad- 
der. Death  is  due  to  exhaustion,  suppression  of  urine,  or 
septic  cystitis.  If  a  foul  catheter  is  used,  septic  cystitis  is 
certain  to  occur;  but  micro-organisms  sometimes  enter  by 
passing  along  the  urethral  mucous  membrane. 

Treatment. — Prevent  cystitis  by  emptying  the  bladder  each 
evening  with  a  Coude  catheter  which  is  strengthened  by  a 
filiform  bougie  as  a  stylet  (Brinton).  Teach  the  patient  to 
use  the  instrument  himself  The  catheter  should  be  kept  in 
corrosive-sublimate  solution  (i  :  5000),  and  before  using  it 
should  be  washed  with  ethereal  soap  and  water  and  then 
with  corrosive  sublimate  (i  :  looo);  after  using  it  should  be 
again  cleansed  and  replaced  in  the  solution.     If  there  is  a 


DISEASES  AND   INJURIES   OF  THE    URETHRA,  ETC.     757 

great  amount  of  residual  urine,  withdraw  only  a  portion  of 
it  at  a  time.  Tell  the  patient  to  avoid  violent  exercise,  cold, 
damp,  sexual  excitement,  and  the  use  of  alcoholic  liquor, 
prevent  constipation  and  indigestion,  and  direct  him  to  drink 
plenty  of  Poland  water.  If  much  residual  urine  exists  or  if 
cystitis  begins,  wash  out  the  bladder  twice  a  week  with 
boracic-acid  solution  and  give  salol  or  boracic  acid  by  the 
mouth.  If  the  suffering  becomes  severe,  if  the  patient  can- 
not urinate  without  the  use  of  an  instrument,  and  if  catheteri- 
zation is  painful,  perform  prostatectomy  by  suprapubic  or 
perineal  incision,  according  to  the  case,  or  drain  by  perineal 
section. 

Retained  Testicle. — The  testicle  may  be  arrested  in  its 
passage  to  the  scrotum  :  it  may  remain  in  the  lumbar  region  ; 
it  may  reach  only  the  internal  abdominal  ring ;  it  may  lodge 
in  the  inguinal  canal ;  it  may  emerge  from  the  external  ring, 
but  fail  to  enter  the  scrotum ;  or  it  may  pass  into  unnatural 
positions,  as  into  the  perineum  or  the  crural  canal.  It  may 
or  may  not  be  functionally  active.  A  retained  testicle  is  sub- 
ject to  repeated  attacks  of  orchitis,  and  it  is  apt  to  become 
sarcomatous.  Sometimes  a  testicle  descends  after  being  re- 
tained for  months. 

Treatment. — If  one  testicle  is  undescended  one  year  after 
birth,  and  the  other  testicle  is  sound,  the  former  should  be 
removed.  In  some  rare  cases  it  is  possible  to  draw  the  gland 
into  the  scrotum  and  fasten  it. 

Orchitis  is  inflammation  of  the  testicle.  Acute  orchitis 
may  be  due  to  cold,  wet,  traumatism  or  epididymitis,  gout, 
mumps,  rheumatism,  or  fever.  The  testicle  is  round,  swollen, 
tender,  and  very  painful,  the  scrotum  is  red  and  swollen,  the 
tunica  vaginalis  fills  with  fluid,  and  there  is  fever.  Chronic 
orchitis  results  from  the  acute  form  or  from  a  chronic 
urethral  inflammation,  and  is  almost  always  combined  with 
epididymitis.     Syphilis  or  tubercle  may  be  responsible  for 


758  A   MANUAL    OF  SURGERY. 

chronic  orchitis.  The  treatment  of  the  acute  form  requires 
rest  in  bed  and  apphcations  as  for  epididymitis  (see  below). 
The  cJiroiiic  form  requires  the  removal  of  the  causative  lesion, 
a  suspensory  bandage,  inunctions  of  ichthyol  or  mercurial 
ointment,  and  iodide  of  potassium  by  the  mouth.  Strapping 
may  do  good.     Castration  may  be  required. 

Castration  (Excision  of  the  Testicle). — In  this  operation 
an  incision  is  made  over  the  cord,  commencing  just  outside 
the  external  ring  and  running  down  over  the  base  of  the 
tumor.  Divide  the  cord  near  to  the  tumor,  remove  the  tes- 
ticle, ligate  the  spermatic  artery  alone,  and  then  ligate  the 
entire  thickness  of  the  cord.  It  is  often  advisable  to  remove 
a  considerable  amount  of  scrotal  skin. 

Epididymitis,  or  inflammation  of  the  epididymis,  is  due  to 
inflammation  of  the  urethra.  It  is  apt  to  occur  in  the  stage 
of  decline  of  a  gonorrhoea,  and  is  announced  by  a  complete 
cessation  of  the  discharge.  Acute  epididymitis  is  character- 
ized by  swelling  about  the  testicle,  pain  in  the  groin,  and 
tenderness  over  the  posterior  part  of  the  testicle.  The  pain 
becomes  acute,  swelling  rapidly  increases,  and  the  constitu- 
tion sympathizes.  The  swelling  is  due  partly  to  engorge- 
ment of  the  epididymis  and  partly  to  fluid  in  the  tunica 
vaginalis  (acute  hydrocele).  Chronic  epididymitis  is  usually 
linked  with  orchitis,  and  it  follows  an  acute  attack  or  a 
chronic  urethral  inflammation.  Treatment  by  puncture  with 
an  aseptic  tenotome,  if  fluctuation  is  marked,  relieves  tension 
and  pain.  Leeching,  the  ice-bag,  elevation,  lead-water  and 
laudanum,  laxatives,  and  opium  are  used  in  the  acute  stage, 
and  strapping  is  employed  as  the  inflammation  subsides. 
The  treatment  of  the  chronic  form  is  the  same  as  that  for 
chronic  orchitis. 

Hydrocele  (chronic  hydrocele)  is  a  collection  of  fluid  in 
the  tunica  vaginalis  testis.  An  enlargement  of  the  testis  can 
cause  it,  but  in  most  instances  the  cause  is  unknown  and  no 


DISEASES  AND   INJURIES  OF  THE    URETHRA,  ETC.     759 

signs  of  inflammation  exist.  The  fluid  is  albuminous,  but  it 
does  not  coagulate  spontaneously ;  it  is  thin,  straw-colored, 
and  may  contain  crystals  of  cholesterin.  The  testicle  is  at 
the  lower  and  back  part  of  the  sac.  The  pyriform  mass 
fluctuates,  is  translucent,  grows  from  below  upward,  and  the 
introduction  of  an  exploring-needle  causes  the  yellow  fluid 
to  flow  out. 

Treatment. — Simply  tapping  the  sac  with  a  trocar  is  only 
palliative,  and,  as  air  must  run  in  as  fluid  runs  out,  suppura- 
tion may  occur,  which  will  be  dangerous  without  drainage. 
Never  tap  a  rigid  sac.  The  injection  of  irritants  should  be 
abandoned,  as  it  exposes  the  patient  to  serious  danger  because 
of  inflammation  occurring  without  provision  for  drainage. 
Hearn  incises  the  sac,  dries  its  interior  with  bits  of  gauze, 
swabs  it  out  with  pure  carbolic  acid,  packs  it  with  iodoform 
gauze,  and  dresses  it  antiseptically.  The  packing  is  removed 
in  twenty-four  hours  and  the  wound  is  allowed  to  close. 
If  the  sac  is  rigid  and  will  not  collapse,  either  stitch  it  to 
the  skin  and  pack  it  or  excise  a  large  portion  of  its  parietal 
layer  and  insert  a  drainage-tube  (Volkmann's  operation). 
It  has  recently  been  proposed  to  tap  the  sac  with  a  trocar 
and  canula,  to  leave  the  canula  in  place  as  a  drain  for  some 
days,  and  to  dress  antiseptically. 

Congenital  hydrocele  is  hydrocele  through  an  unclosed 
funicular  process  into  the  tunica  vaginalis.  If  the  pelvis  is 
raised  the  fluid  runs  back  into  the  peritoneal  cavity,  from 
which  it  originally  came.  The  treatme^it  is  a  truss  to  oblit- 
erate the  funicular  process. 

Infantile  hydrocele  is  a  collection  of  fluid  in  a  funicular 
process  and  the  tunica  vaginalis,  the  funicular  process  being 
closed  above,  but  not  below.  The  treatment  is  to  puncture 
the  sac  and  to  scarify  the  sac-wall  with  a  needle. 

Encysted  Hydrocele  of  the  Cord. — In  this  variety  the 
funicular  process  is  obliterated  above  and  below,  but  it  is 


76o  A   MANUAL    OF  SURGERY, 

patent  between  these  two  points,  and  fluid  collects.  The 
treatment  is  the  same  as  that  for  infantile  hernia.  If  this 
fails,  incise  and  pack. 

Funicular  Hydrocele. — The  funicular  process  is  closed 
below,  but  is  open  above.  Raising  the  pelvis  causes  the 
fluid  to  trickle  back  into  the  peritoneal  cavity.  The  treat- 
ment is  a  truss. 

Encysted  hydroceles  of  the  testicles  and  of  the  epididymis 
can  occur.  Diffused  hydrocele  of  the  cord  is  simply  oedema 
of  the  cord.  Hydrocele  of  a  hernia  is  the  distention  of  a 
hernial  sac  with  peritoneal  fluid. 

Hsematocele. —  Vaginal  hcematocele  is  blood  in  the  tunica 
vaginalis,  the  result  of  traumatism,  a  tumor,  or  the  tapping 
of  a  hydrocele.  There  is  a  pyriform  tumor,  which  fluctu- 
ates, but  which  gradually  becomes  firmer ;  the  scrotum  is 
livid,  and  the  testicle  is  below  and  posterior  to  the  tumor. 
The  encysted  form  of  hcematocele  of  the  cord  is  a  hydrocele 
of  the  cord  into  which  bleeding  has  occurred.  The  diffused 
form  is  due  to  extravasation  of  blood  into  the  cellular  sub- 
stance of  the  cord.  Encysted  hcEmatoccle  of  the  testicle  is  due 
to  eflusion  of  blood  into  an  encysted  hydrocele  of  the  testicle. 
Parenchymatous  hcematocele  is  extravasation  of  blood  into 
the  substance  of  the  testicle.  The  treatment  of  a  recent  case 
of  vaginal  haematocele  is  to  put  the  patient  to  bed,  support 
the  scrotum,  and  apply  an  ice-bag  over  the  testicle.  If  the 
swelling  does  not  soon  abate,  incise,  irrigate,  and  pack. 

Varicocele  is  varicose  enlargement  of  the  veins  of  the 
pampiniform  plexus.  An  irregular  swelling  exists. in  the  scro- 
tum and  extends  up  the  cord.  This  swelling  feels  like  "a  bag 
of  earth-worms  ; "  it  exhibits  a  slight  impulse  on  coughing ; 
the  scrotal  skin  and  cremaster  muscle  are  attenuated ;  the 
testicle  lies  at  the  bottom  of  the  swelling  and  is  softer  and 
smaller  than  normal ;  the  swelling  diminishes  on  lying  down 
and  increases  on  standing  or  on  making  pressure  over  the 


AMPUTA  TIOXS.  76 1 

external  ring.  There  is  usually  some  discomfort,  aching,  or 
dragging  in  the  testcle  or  the  groin,  and  even  neuralgic  pain 
in  the  cord.  There  is  sometimes  mental  depression  and 
hypochondria.  In  treating  varicocele,  reassure  the  patient : 
tell  him  there  is  no  real  danger  of  impotence ;  order  cold 
shower-baths,  correct  constipation  and  indigestion,  give  occa- 
sional tonics,  and  order  the  patient  to  wear  a  suspensory 
bandage.  If  the  testicle  becomes  much  atrophied,  if  the 
pain  and  the  dragging  are  annoying,  or  if  the  mind  is  much 
depressed,  operate  (see  p.  261). 

XXXVI.    AMPUTATIONS. 

An  amputation  is  the  cutting  off  of  a  limb  or  a  portion 
of  a  limb.  Removal  of  a  limb  or  a  portion  of  a  limb  at  a 
joint  is  known  as  '*  disarticulation."  Amputation  may  be 
necessary  because  of  the  existence  of  severe  injury,  of  gan- 
grene, of  tumors,  of  intractable  disease  of  bones  or  joints, 
of  ulcers  which  will  not  heal,  of  traumatic  aneurysm,  etc. 
A  re-amputation  may  be  required  because  of  the  existence 
of  a  defect  or  disease  in  the  stump. 

Classificatioii. — Amputations  are  classified  as  follows  :  (i) 
As  to  time  after  the  injury  of  operation  :  a  priniajy  amputa- 
tion is  performed  soon  after  the  occurrence  of  the  accident — 
as  soon  as  the  sufferer  reacts  from  shock,  and  before  he 
develops  fever ;  a  secondary  amputation  is  performed  some 
time  after  the  accident,  suppuration  having  supervened 
(Stokes);  and  an  intermediate  amputation  is  performed  during 
the  existence  of  fever,  but  before  the  developm.ent  of  sup- 
puration. (2)  As  to  the  situation,  where  the  bone  is  divided 
or  according  to  which  joint  is  cut  through.  (3)  As  to  the 
form  and  situation  of  the  flap. 

In  performing  an  amputation,  maintain  rigid  asepsis  ;  com- 
pletely remove  the  hopelessly-damaged  portion  ;  sacrifice  as 


762  A   MANUAL    OF  SURGERY. 

little  of  the  sound  tissue  as  possible;  prevent  hemorrhage 
during  the  amputation,  and  carefully  arrest  it  after  the  opera- 
tion ;  have  enough  sound  tissue  in  the  flap  to  cover  the  bone, 
and  enough  skin  to  cover  the  muscles;  and  secure  drainage 
at  a  dependent  point. 

Hemorrhage    is    prevented    by    the    elastic    bandage   of 
Esmarch.     In  an  ordinary  case  apply  this  bandage  from  the 
periphery  to  well  above  the  line  of  the  prospective  incision, 
encircle  the  limb  with  the  elastic  band  (not  a  thin  tube),  and 
remove  the   bandage.     The  bandage  and  band,  which  are 
asepticized  before  using,  are  applied  to  a  limb  wrapped  with 
antiseptic  towels.     After  the  band  has  been  applied  the  limb 
should  not  freely  or  forcibly  be  moved,  because  of  the  danger 
of  tearing  muscles  which  are  firmly  set  by  the  compressing 
band.    When  elastic  compression  is  used  in  an  operation  the 
surgeon  should  be  very  careful  to  tie  every  visible  vessel. 
The  paralysis  of  the  small  vessels  induced  by  pressure  often 
prevents  bleeding,  and  unless  their  mouths  be  found  and  the 
vessels  be  tied  secondary  hemorrhage  will  occur.    Secondary 
hemorrhage  is  the  great  danger  from  the  Esmarch  bandage, 
and  paralysis  or  sloughing  may  also  follow  its  use.     If  there 
be  an  area  of  suppuration  or  of  gangrene  or  an  extra-osseous 
malignant  growth,  do  not  apply  the  bandage  as  directed 
above.     One  bandage  can  be  applied  from  the  periphery  to 
near  the  lower  border  of  the  area  of  growth  or  infection,  and 
another,  from  near  the  upper  border  of  this  area,  up  the  limb. 
The  contents  of  the  area  (tumor-cells  and  fluids  or  septic 
products)  are  not  squeezed  into  the  circulation.     In   cases 
like  the  above  many  surgeons  hold  the  extremity  in  a  ver- 
tical position  for  five  minutes,  lightly  stroking  it  toward  the 
body  with  the  hand,  and  at  once  apply  the  constricting  band. 
Some    surgeons   prefer   the    tourniquet.      To    apply   Petit's 
tourniquet,  place  the  plates  in  contact,  apply  a  small  firm 
compress  over  the  artery  and  a  broad  thick  compress  over 


AMPUTA  TIONS. 


763 


Fig.  172.  —  Catiin,  Knife,  and  Saws  for  Amputations. 


Fig.  173. — Modified  Circular    Amputa- 
tion of  the  Forearm  (Bryant). 


Fig.  174. — Amputation  of  Arm 
by  the  Circular  Method  (Druittj. 


Fig.    175. — Amputation  of   the   Thigh 
by  Transfixion  (Gross). 


Fig.    176. — Amputation   of  the   Leg 
by  a  Long  Posterior  Flap  (Gross). 


Fig.  178. — Lisfranc's  Amputation  :  first  step  (Guerin 


Fig.  177. — Sedillot's  Amputation  of      Fig.  179. — Lisfranc's   Amputation:    second  step 
the  Leg  (Wyeth).  (Guerin). 


764  A   MANUAL    OF  SURGERY. 

the  outer  surface  of  the  hnib,  buckle  the  tapes  around  the 
hnib  so  that  the  plate  is  over  the  broad  pad,  and  tighten  the 
tourniquet  by  separating  the  plates  with  the  screw.  When  a 
tourniquet  is  applied  to  arrest  bleeding  during  transporta- 
tion, bandage  the  limb,  sew  the  compress  pad  to  the  band- 
age, and  place  the  plates  of  the  instrument  over  the  pad. 
Signorini's  horseshoe  tourniquet  may  be  used  upon  the 
brachial  artery.  In  hip-joint  and  shoulder-joint  amputations 
Wyeth's  pins  are  passed,  and  after  the  limb  is  emptied  of 
blood  the  band  is  fastened  above  them.  These  pins  prevent 
the  bands  from  slipping. 

The  instruments  and  appliances  required  are  Esmarch's 
apparatus  or  tourniquet,  amputating-knives,  a  bone-knife, 
scalpels,  saws,  a  lion-jawed  forceps,  bone-cutting  forceps, 
a  periosteum-elevator,  retractors  of  linen,  dissecting,  haemo- 
static, and  toothed  forceps,  a  tenaculum,  an  aneurysm-needle, 
a  probe,  scissors,  needles,  ligatures,  sutures  of  silkworm  gut, 
dressings,  bandages,  and  solutions.  A  retractor  has  two  tails 
for  the  thigh  and  arm  and  three  tails  for  the  leg  and  fore- 
arm ;  it  is  made  by  taking  a  piece  of  muslin  eight  inches 
wide  and  twelve  inches  long  and  cutting  tails  on  one  side 
eight  inches   in  length. 

Methods  of  Amputating- :  Circular  Method  (Fig.  174). — 
The  surgeon  should  stand  to  the  right  of  the  limb  and  use  a 
long  amputating-knife  which  cuts  from  heel  to  point.  After 
an  assistant  has  retracted  the  skin  the  operator  divides  the 
soft  parts  by  a  series  of  circular  cuts.  Do  not  cut  at  once 
to  the  bone,  but  divide  the  skin  and  subcutaneous  tissues. 
At  the  retracted  edge  of  the  first  cut  divide  the  superficial 
muscles,  and  after  these  muscles  retract  divide  the  deep 
muscles.  Incise  the  periosteum  with  a  bone-knife,  push  up 
the  periosteum  with  an  elevator,  and  after  the  application 
of  the  retractors  saw  the  bone.  A  periosteal  flap  can  be 
made  to  cover  the  end  of  the  bone,  but  it  is  unnecessary. 


AMPUTA  TIONS. 


765 


Fig.    180.— Circular    Amputation:    dissecting 
up  the  skin-flap  (Esmarch). 


In  this  amputation  is  formed  a  cone  whose  apex  is  the 
bone  and  whose  base  is  the  skin-edge.  In  one  form  of  cir- 
cular amputation  (a^npu- 
lation  a  la  inancJiettc)  the 
retracted  skin  is  cut  by  a 
circular  sweep  of  the  knife, 
a  cuff  of  skin  and  subcu- 
taneous tissue  is  freed  and 
turned  up,  and  the  muscles 
are  cut  circularly  at  the 
edge  of  the  turned-up  cut 
(Fig.  180).  The  pure  cir- 
cular amputation  is  per- 
formed on  the  arm  and  the 
thigh  ;  the  amputation  a  la  ma7ichctte  is  performed  chiefly 
through  the  wrist  and  the  lower  forearm. 

Modified  Circular  Method. — In  this  operation  the  cir- 
cular skin-cut  may  be  modified  by  making  a  vertical  incision 
to  join  the  first  wound, 
the  muscles  being  cut  by 
a  circular  sweep  or  by 
making  two  vertical  skin- 
incisions.  Liston's  modi- 
fication consists  in  dis- 
secting up  two  short  semi- 
lunar integumentary  flaps 
and  in  dividing  the  mus- 
cles circularly  This  is 
known  as  the  "  mixed  method"  (Fig.  181).  The  modified 
circular  can  be  used  upon  the  thigh,  the  leg,  the  arm,  and 
the  forearm. 

Elliptical  Method. — This  method  stands  midway  between 
the  circular  operation  and  the  operation  by  a  single  flap. 
An  elliptical  incision  is  made  through  the  skin  and  subcu- 


FiG.  181. — Modified  Circular  Amputation :  skin- 
flaps  and  circular  through  muscles  (Esmarch). 


766  A   MANUAL    OF  SURGERY. 

taneous  tissues,  the  tissues  are  pushed  up  or  turned  back, 
and  the  muscles  are  divided  circularly  or  cut  partly  by  trans- 
fixion.   This  method  is  employed  in  certain  disarticulations. 

Oval  or  Racket  Method. — In  an  oval  amputation  the 
incision  through  the  skin  and  subcutaneous  tissue  is  an  oval 
with  a  pointed  end  or  a  triangle,  and  the  other  parts  down 
to  the  bone  are  cut  from  without  inward.  When  a  longi- 
tudinal incision  down  to  the  bone  (Fig.  184,  A,  b)  extends 
from  the  point  of  the  oval  (in,  h),  the  operation  is  called  the 
"racket"  amputation.  If  the  longitudinal  cut  joins  a  cir- 
cular cut,  the  operation  is  known  as  a  "T"  amputation.  The 
oval  or  racket  operation  is  performed  at  the  metacarpo- 
phalangeal, metatarso-phalangeal,  and  shoulder-joints ;  the 
T  operation  may  be  performed  at  the  hip-joint. 

Flap  Method. — A  flap  may  be  composed  of  skin  only  or 
of  both  skin  and  muscle,  but  the  skin  must  always  be  cut 
longer  than  the  muscle,  so  that  the  latter  will  be  covered 
by  it.  A  flap  containing  much  muscle  heals  badly,  but  the 
best  flap  has  a  moderate  amount  of  muscle  (enough  skin  to 
cover  the  muscle  and  enough  muscle  to  cover  the  bone). 
Flaps  may  be  single  or  double.  Double  flaps  may  be  lateral 
or  antei'o-posterior,  square  or  \S -shaped,  eq2ial  or  unequal,  and 
they  may  be  cut  by  transfixion  (Fig.  175),  by  cutting  from 
without  inward,  by  dissection,  or  by  cutting  the  skin  from 
without  inward  and  the  muscles  by  transfixion.  When  an 
amputation  is  completed,  irrigate,  tie  the  main  vessels,  pull 
down  the  nerves  and  cut  them  off,  smooth  the  flaps,  take  off 
the  constricting  band,  and  after  arresting  hemorrhage  apply 
sutures.  In  some  cases  the  deep  parts  are  stitched  with  a 
continuous  catgut  ligature  and  the  superficial  parts  are  closed 
with  silkworm  gut ;  in  other  cases  the  deep  parts  are  not 
stitched  at  all,  the  skin  alone  being  sutured  with  silkworm 
gut.  Drainage-tubes  should  be  used  except  in  amputations 
of  the  fingers  and  toes. 


AMPUTA  TIONS.  767 

Special  Amputations :  Fing-ers  and  Hand. — In  ampu- 
tating the  thumb  and  index  finger,  save  every  possible  scrap 
of  tissue.  In  either  of  the  other  fingers,  if  it  be  necessary 
to  amputate  above  the  middle  of  the  middle  phalanx,  the 
attachment  of  the  flexor  tendons  will  be  cut  off  and  the 
finger  will  be  liable  to  project  directly  backward,  so  that  it  is 
better  with  these  fingers  either  to  disarticulate  at  the  meta- 
carpal joints  or  to  stitch  the  flexor  tendons  to  the  perios- 
teum. .  The  flexor  tendons  have  fibrous  sheaths  extending 
from  the  proximal  end  of  the  distal  phalanx  to  the  meta- 
carpo-phalangeal  articulations,  these  sheaths  being  thin 
and  collapsible  opposite  the  joints,  but  being  thick  and  rigid 
opposite  the  shafts  of  the  bone.  The  fibrous  sheath  is 
known  as  the  thcca,  and  when  it  is  cut  in  an  amputation  it 
should  be  closed,  otherwise  it  may  carry  infection  to  the 
palm  of  the  hand.  The  theca  does  not  exist  over  the  distal 
phalanx,  and  it  is  not  distinctly  visible  over  the  joint  between 
the  distal  and  middle  phalanges.  To  effect  closure  over  the 
shaft  of  a  bone,  strip  up  the  periosteum  and  pass  catgut 
sutures  vertically  through  the  theca  and  the  periosteum 
(Treves).  In  amputation  of  the  fingers  and  the  thumb  an 
Esmarch  bandage  is  unnecessary,  though  pressure  may  be 
made  upon  the  arteries  in  the  wrist.  Ligatures  are  often 
unnecessary.  Close  with  a  very  few  sutures,  so  as  to  favor 
drainage  between  the  threads. 

The  distal  phalanx  is  best  removed  by  a  long  palmar  flap 
(Fig.  182,  a).     The  palmar  flap  (a)  is  marked  out  by  cutting 

through  the  skin  and  subcutaneous  tissue.         ^ 

The  incisions  are  next  carried  to  the  bone,    //^\^—-\^^"^ 
the  flap  is  dissected  from  the  bone,  the     a      ^         o\^ 
finger  is  strongly  flexed,  a  transverse  in-     fig.  i82.-Amputation 
cision  (b)  is  carried  across  the  dorsum  on  °^  ^^^  F>nger. 
a  level  with  the  base  of  the  third  phalanx,  the  soft  parts  are 
pushed  back,  the  joint  is  opened,  the  lateral  ligaments  are 


76^ 


A   MANUAL    OF  SURGERY. 


cut  from  within  outward,  the  third  phalanx  is  forcibly  ex- 
tended, and  the  remaining  structures  are  cut  from  below 
upward.  The  middle  phalanx  can  be  removed  by  the  same 
method  (c).  The  proximal  phalanx  can  be  removed  by  a 
long  palmar  flap  or  by  a  long  palmar  and  a  short  dorsal  flap 
(d,  e). 

Disarticulation  of  a  metacarpo-phalang'eal  joint  is  best 
performed  by  the  oval  or  racket  method.  The  incision  upon 
the  dorsum  (a)  is  begun  just  above  the  head  of  the  meta- 
carpal bone,  is  carried  down  to  beyond 
the  base  of  the  phalanx,  and  involves  the 
skin  only  (Fig.  183).  One  incision  sweeps 
around  the  finger  at  the  level  of  the  web, 
going  only  through  the  skin  (b)  ;  the  finger 
is  extended  and  the  palmar  cut  is  carried 
to  the  bone ;  each  lateral  incision  is  car- 
ried to  the  bone  while  the  finger  is  bent 
in  the  opposite  direction,  the  flaps  are 
dissected  back  to  the  joint,  the  finger  is 
strongly  extended,  the  joint  is  opened 
from  the  palmar  side,  and  disarticulation 
is  effected.  Cutting  off  the  head  of  the  metacarpal  bone 
improves  the  appearance  of  the  stump  but  weakens  the  hand, 
hence  in  a  working-man  it  must  not  be  done.  If  it  is  neces- 
sary to  remove  a  metacarpal  bone,  the  incision  (c)  is  made 
from  the  carpo-metacarpal  joint. 

Amputation  of  the  thumb  through  its  distal  or  proximal 
phalanx  is  performed  identically  as  is  an  amputation  of  a 
finger.  Amputation  of  the  thumb  with  a  portion  or  the 
whole  of  its  metacarpal  bone  is  performed  by  the  oval  or 
racket  incision. 

Amputation  at  the  "wrist-joint  can  be  done  by  the  circu- 
lar method  or  by  a  double  flap.  In  the  double-flap  amputa- 
tion (Fig.  98,  I,  2)  a  dorsal  flap  is  made  by  carrying  a  semi- 


FiG.  183. — Disarticula- 
tion of  a  Metacarpo-pha- 
langeal  Joint. 


AM  PUT  A  TIONS.  769 

lunar  skin-incision  between  the  styloid  processes ;  the  skin 
is  lifted  up,  the  wrist  is  forcibly  flexed,  the  joint  is  opened  by 
a  transverse  cut,  and  a  long  semilunar  palmar  flap  is  made 
by  dissection,  which  flap  includes  only  the  skin  and  fascia. 

Amputation  through  the  forearm  may  be  done  as  a 
circular  (Fig.  174),  a  modified  circular,  or  a  flap  operation. 
An  excellent  plan  is  to  make  a  semilunar  dorsal  skin-flap 
(Fig.  98,  3)  and  a  semilunar  skin-flap  on  the  flexor  surface 
(Fig.  98,  4).  The  flaps  are  raised,  the  muscles  are  cut  circu- 
larly (Fig.  173),  the  interosseous  space  is  cleared  with  the 
knife,  a  three-tailed  retractor  is  applied,  the  periosteum  is 
pushed  up,  and  the  bones  are  sawn  half  an  inch  above  the 
flap.  In  sawing  the  bones,  start  the  saw  upon  the  radius, 
draw  it  from  heel  to  point,  make  a  furrow  on  the  radius  and 
ulna,  and  saw  both  bones  together.  After  sawing,  cut  away 
any  irregular  edge  with  bone-pliers.  In  the  lower  third 
Teale's  amputation  may  be  done,  the  dorsal  flap  being  the 
long  one  (Fig.  97,  i).  In  Teale's  amputation  rectangular 
flaps  are  made.  The  long  flap  is  equal  in  width  and  length 
to  one- half  the  circumference  of  the  limb  at  the  point  where 
it  is  to  be  sawn.  The  short  flap  is  equal  in  width  to  the 
long  flap,  but  is  only  one-fourth  its  length.  The  two  longi- 
tudinal cuts  are  at  first  taken  onlv  throusfh  the  skin,  but  the 
two  transverse  cuts  go  at  once  to  the  bone.  The  flaps  are 
dissected  up  from  the  interosseous  membrane  and  the  bone. 
In  the  middle  or  the  upper  third  of  a  fleshy  arm  two  semi- 
lunar skin-flaps  can  be  cut  from  without  inward,  and  the 
muscle  can  be  cut  by  transfixion. 

Disarticulation  of  the  elbow-joint  can  be  done  by  the 
elliptical  method  or  by  a  long  anterior  flap  and  a  short  poste- 
rior flap.  In  the  latter  operation  the  forearm  is  partly  flexed 
and  a  skin-cut  marks  out  a  long  anterior  flap,  the  knife 
being  entered  opposite  the  external  condyle  and  being  with- 
drawn one  inch  below  the  internal  condyle  (Fig.  98,  5). 
49 


J  JO  A   MANUAL    OF  SURGERY. 

The  muscles,  which  are  bunched  forward,  are  cut  by  trans- 
fixion. A  posterior  semilunar  flap  is  made  (Fig.  lOO,  i), 
which  separates  the  attachments  of  the  radius,  the  ulna  is 
cleared,  and  the  triceps  is  cut  at  its  insertion  (Bell).  Gross 
advocated  sawing  through  the  olecranon  and  the  inner  troch- 
lear surface. 

Amputation  of  the  arm  is  best  performed  by  marking 
out  w^ith  a  knife  two  equal  semilunar  antero-posterior  flaps, 
the  knife  cutting  through  the  skin,  the  muscles  then  being 
transfixed  with  a  long  knife  (Fig.  99,  i).  Teale's  method  is 
shown  in  Figure  98  (6).  The  circular  or  the  modified  circu- 
lar amputation  may  be  performed. 

Disarticulation  at  the  Shoulder-joint. — In  this  operation 
Wyeth's  pins  must  be  passed  to  prevent  hemorrhage.  The 
anterior  pin  is  entered  at  the  middle  of  the  lower  margin  of 
the  anterior  axillary  fold,  and  emerges  one  inch  within  the 
tip  of  the  acromion.  The  posterior  pin  is  entered  at  a  cor- 
responding point  on  the  posterior  axillary  fold,  and  emerges 
more  posteriorly  than  the  first  pin  and  an  inch  within  the 
tip  of  the  acromion. 

Larrey's  Operation. — In  this  method  of  shoulder-joint  dis- 
/  articulation  the  limb  is  held  from  the  side  and 

an  incision  is  made  down  to  the  bone,  the  in- 
cision beginning  just  below  and  in  front  of  the 
acromion  and  running  vertically  for  four  inches 
down  the  outer  surface  of  the  arm  (Fig.  184, 
A,  b).  From  the  centre  of  this  incision  an  oval 
incision  is  carried  around  the  arm,  the  inner 

Fig.  184.— Ampu- 

tation  at  the  shoui-  aspcct  of  the  oval  reachmg  as  low  as  the  lower 
der-joint:A,E,Lar-   ^^^  of  the  vcrtical  cut  U,  b).     The  oval   in- 

rey's  operation;   i, 

2,  Dupuytren's  op-  cisiou  at  first  iuvolvcs  Only  the  skin  and  sub- 
^''^^'°"'  cutaneous  tissues.     The  anterior  structures  are 

divided  close  to  the  bone,  and  the  posterior  structures  are 
next  cut.    To  disarticulate,  cut  the  capsule  transversely  upon 


AMPUTA  TIONS. 


m 


the  head  of  the  bone ;  while  the  arm  is  rotated  outward  cut 
the  subscapulars,  and  while  the  arm  is  rotated  inward  cut 
the  supraspinatus  and  infraspinatus  and  the  teres  minor. 
Cut  away  any  tissue  holding  the  humerus  to  the  body,  cut 
away  hanging  nerves,  capsule-fragments,  and  tissue-shreds, 
and  sew  up  the  wound  vertically.  Bell  advises  an  oval  in- 
cision without  a  racket  handle  (Fig.  98,  7).  Spence  used  an 
anterior  racket  incision. 

Dupiiyircn  s  Method. — In  Dupuytren's  shoulder-joint  dis- 
articulation a  U-shaped  flap  is  marked  out  by  a  skin-incision 
(Fig.  184,  I,  2;  Fig.  97,  3).  In  the  right  shoulder  the  arm 
is  carried  across  the  chest ;  the  knife  is  entered  at  the  root 
of  the  acromion,  follows  the  margin  of  the  deltoid,  and  is 
withdrawn  at  the  coracoid  process,  the  arm  being  gradually 
abducted  and  pulled  off  from  the  chest.  In  the  left  shoulder 
the  procedure  is  reversed  (Treves).  The  knife  now  cuts 
through  the  deltoid  and  raises  a  flap  composed  of  this  mus- 
cle, the  shoulder-joint  is  exposed,  and  disarticulation  is  ef- 
fected as  in  Larrey's  method.  The  knife  is  passed  down  back 
of  the  bone  and  a  short  internal  flap  is  cut. 
Lisfranc's  amputation  is  by  transfixion  with 
the  formation  of  an  anterior  and  a  posterior 
flap,  and  can  be  performed  very  rapidly,  but 
only  a  most  skilful  surgeon  should  attempt  it. 

Amputation  of  the  Toes  and  the  Foot. — 
Only  in  the  great  toe  is  partial  amputation 
performed,  and  it  is  performed  by  a  long 
plantar  flap  as  is  done  in  the  finger.  Am- 
putation at  the  metatarso-phalangeal  joints  is 
performed  by  an  oval  or  racket  incision  (Fig.  pj^  185.— Ampu- 
185).     Amputation  of  a  toe  with  removal  of    tation  of  Metatarsal 

•  1  •        -r-'-  r.  Bones. 

its  metatarsal  bone  is  shown  in  rigure   185. 

Amputation   at    the   Tarso-metatarsal  Articulation. — 
Lisfranc's  Method  (right  foot,  after  Treves). — Begin  an  incis- 


J']2  A   MANUAL    OF  SURGERY. 

ion  on  the  outer  border  of  the  foot,  behind  the  tubercle  of 
the  fifth  metatarsal  bone  ;  carry  the  incision  forward  one  inch 
and  sweep  it  across  the  foot  half  an  inch  below  the  tarso- 
metatarsal articulations;  bring  the  incision  to  the  inner  edge 
of  the  foot,  half  an  inch  in  front  of  the  tarsal  articulation  of 
the  big  toe,  and  carry  the  cut  straight  along  the  inner  margin 
of  the  foot  until  it  reaches  a  point  three-fourths  of  an  inch 
above  the  articulation  of  the  metatarsal  bone  of  the  great  toe. 
A  semilunar  dorsal  skin-flap  is  thus  formed  (Figs.  178,  179). 
After  the  skin-flap  is  dissected  back  for  a  quarter  of  an 
inch  the  tendons  are  divided,  and  the  flap,  which  now 
contains  all  the  soft  parts,  is  dissected  back  to  above  the 
joint.  A  long  plantar  flap  is  cut,  reaching  from  the  origin 
of  the  first  flap  to  the  necks  of  the  metatarsal  bones.  The 
skin-flap  is  dissected  up  until  the  hollow  behind  the  heads 
of  the  metacarpal  bones  is  reached,  when,  with  the  toes  in 
extension,  the  tendons  are  cut  across  and  a  flap  composed 
of  all  the  soft  parts  is  dissected  up  to  above  the  tarso-meta- 

f  tarsal  joint.  The  joint  is  opened  from  the 
outer  side  according  to  the  following  rule  : 
In  separating  the  fifth  metatarsal,  direct  the 
edp;e  of  the  knife  toward  the  distal  end  of 
the  first  metatarsal ;  in  separating  the  fourth 
metatarsal,  direct  the  knife  toward  the 
middle  of  the  first  metatarsal ;  in  separat- 
ing^ the  third  metatarsal,  carry  the  knife 
almost  directly  across.  Figure  186  shows 
the  line  of  Lisfranc  at  the  tarso-metatarsal 
articulation.     The  separation  is  facilitated 

Fig.  186. — Lines  in  Am-  ^ 

putations  of  the  Foot  by  bending  down  the  front  of  the  foot,  and 
^^^°^^^-  at  the  same  time  the  tendons  of  the  pero- 

neus  brevis  and  tertius  are  divided.  Open  the  joint  between 
the  first  metatarsal  and  the  inner  cuneiform  bone,  turning  the 
knife  toward  the  middle  of  the  shaft  of  the  fifth  metatarsal, 


AMPUTATIONS.  773 

and  at  the  same  time  div^ide  the  tibiahs  anticus  muscle. 
Treves  says  that  in  disarticulation  of  the  second  metatarsal 
the  knife  is  to  be  held  as  a  trocar,  it  is  to  be  thrust  between  the 
base  of  the  first  and  second  metatarsal  bones  until  the  point 
strikes  bone  (Fig.  178),  and  is  then  to  be  raised  to  a  perpen- 
dicular and  the  cut  is  to  be  made  toward  the  external  malle- 
olus to  sever  the  ligament  of  Lisfranc  (Fig.  179).  Divide, 
any  remaining  ligaments,  and  also  the  tendon  of  the  peroneus 
longus  muscle.  The  skin-incisions  in  the  left  foot  are  begun 
on  the  inner  side,  and  in  disarticulating  the  tarsal  joint  of 
the  great  toe  is  first  opened. 

Hcys  Method. — In  Hey's  method  the  incision  is  practically 
the  same  as  that  for  Lisfranc's  amputation  (Fig.  98,  8,  9). 
The  four  external  metacarpal  bones  are  disarticulated,  but 
the  first  metatarsal  is  removed  by  sawing  a  portion  of  the 
internal  cuneiform  bone.  Guerin  advised  sawing  all  the  bones 
across.  Skey  advised  the  division  of  the  head  of  the  second 
metatarsal.     Figure  186  shows  the  line  of  Hey. 

Amputation  through  the  Middle  Tarsal  Joint. —  Clioparfs 
Amputation. — Make  a  transverse  incision  through  the  skin 
of  the  instep,  two  inches  below  the  ankle-joint;  cut  the  ten- 
dons and  muscles,  expose  the  tarsus  (Fig.  97,  4,  5),  and 
make  on  each  side  a  small  longitudinal  incision  reaching  to 
below  and  in  front  of  the  corresponding  malleolus.  The 
flap  thus  formed  is  retracted.  The  plantar  flap  is  made  as  in 
Lisfranc's  amputation.  Open  the  astragalo-scaphoid  joint, 
then  the  calcaneo-cuboid  joint,  and  disarticulate.  Figure  186 
shows  the  line  of  Chopart.  In  amputation  through  the  tarsus 
Forbes  of  Toledo  advises  making  flaps  as  in  Chopart's  am- 
putation, disarticulating  the  scaphoid  from  the  cuboid  bones, 
and  sawing  through  the  cuboid.  Figure  186  shows  the  line 
of  P^orbes. 

Amputation  at  the  Ankle-joint. — Syjnes  Method. — The 
foot  is  held  at  a  right  angle  to  the  leg,  and  a  skin-incision  is 


774  ^   MANUAL    OF  SURGERY. 

carried,  from  just  below  the  external  malleolus,  straight 
across  or  a  little  backward  across  the  sole  to  a  correspond- 
ing point  on  the  opposite  side  (Fig.  98,  10,  11).  Do  not  take 
this  incision  near  to  the  inner  malleolus,  as  to  do  so  will  en- 
danger the  posterior  tibial  artery.  The  incision  is  carried  to 
the  bone,  the  flap  being  pushed  back  and  separated  from  the 
bone  by  means  of  a  strong  knife  and  the  thumb-nail  until 
the  tuberosity  of  the  os  calcis  has  been  reached.  The  foot 
is  now  extended  and  a  transverse  cut  is  made  across  the 
dorsum,  joining  the  two  ends  of  the  first  incision  (Fig.  98, 
10,  11);  the  ankle-joint  is  opened,  the  lateral  ligaments  are 
cut,  disarticulation  is  effected,  and  the  foot  is  finally  com- 
pletely removed  by  severing  the  tendo  Achillis.  A  thin 
piece  of  bone  including  both  malleoli  is  sawn  from  the  tibia 
and  fibula.  The  flap  is  perforated  posteriorly  to  secure 
drainage. 

Pirogoff's  Method. — In  this  method  of  ankle-joint  ampu- 
tation the  incisions  are  the  same  as  those  for  Syme's  amputa- 
tion. Do  not  dissect  the  flap  from  the  posterior  portion  of  the 
OS  calcis,  but  saw  off  this  bony  projection  obliquely  and  leave 
it  adherent  to  the  tissues.  The  saw  is  used  after  disarticula- 
tion of  the  ankle-joint;  it  is  passed  behind  the  astragalus, 
cuttincr  downward  and  forward.  The  ends  of  the  tibia  and 
fibula  are  sawn  off,  and  the  sawn  os  calcis  is  brought  into 
contact  with  the  sawn  tibia  and  fibula. 

Amputations  of  the  Leg". — In  amputations  of  the  leg  by 
the  long  antcrioj'  flap,  cut  through  the  skin  (Fig.  99,  4,  5), 
dissect  up  the  anterior  muscles  with  the  flap,  and  cut  all  the 
posterior  tissues  with  a  single  transverse  sweep.  In  ampu- 
tation by  rectangular  flap  Teale's  method  is  very  useful 
(Fig.  98,  12,  13). 

Sedillot's  leg-ainputation  (Fig.  177)  is  by  a  long  exter- 
nal flap.  A  longitudinal  incision  is  made  along  the  inner 
edge  of  the  tibia,  the  tissues  are  drawn  toward  the  fibula, 


AMPUTATIONS.  7/5 

a  knife  is  introduced  and  passed  to  the  outer  edge  of  the 
tibia,  just  touching  the  fibula,  and  is  brought  out  posteriorly, 
thus  transfixing  the  calf-muscles  and  cutting  an  external  flap. 
A  convex  incision  is  made  on  the  inner  side,  the  bones  are 
cleared  and  are  sawn  one  inch  above  the  flaps,  half  an  inch 
more  being  taken  from  the  fibula  than  from  the  tibia,  and 
the  tibia  being  bevelled  anteriorly. 

Modified  Circular  Amputation  of  the  Leg-. — Cut  semi- 
lunar skin-flaps  (Fig.  99,  6,  7),  lay  them  back,  and  cut  circu- 
larly to  the  bone  at  the  edge  of  the  turned-up  flap.  Another 
method  of  modified  circular  amputation  is  by  adding  to  the 
circular  cut  a  vertical  incision  down  the  front  of  the  leg.  In 
sawing  the  bones  of  the  leg,  the  surgeon,  who  stands  on  the 
outer  side  of  the  right  leg  or  on  the  inner  side  of  the  left 
leg,  divides  the  fibula  first,  and  at  a  higher  level  than  the 
tibia,  and  bevels  the  anterior  surface  of  the  tibia.  In  sawing 
the  left  fibula  the  saw  points  to  the  floor  ;  in  sawing  the 
right  fibula  it  points  to  the  ceiling. 

Amputation  of  the  Leg  by  a  Long-  Posterior  and  a  Short 
Anterior  Flap. — In  this  operation  a  posterior  U-shaped  flap 
is  made,  equal  in  length  and  breadth  to  the  diameter  of 
the  limb.  The  skin-incision  is  begun  one  inch  below  the 
point  where  the  bone  is  to  be  sawn,  and  behind  the  inner 
edge  of  the  tibia,  and  is  carried  to  a  point  posterior  to  the 
peronei  muscles.  The  gastrocnemius  muscle  is  divided  trans- 
versely at  the  level  of  the  flap,  the  soft  parts  on  either  side 
in  the  line  of  the  flap  being  cut  to  the  bone.  Through  these 
vertical  cuts  the  muscles  are  lifted  from  the  bones  and  are 
divided  through  their  lower  part  by  cutting  from  within 
outward.  The  anterior  flap  is  formed  by  making  a  semi- 
lunar skin-flap  and  by  cutting  the  muscles  across  at  its 
retracted  edge  (Fig.  176).  Ainpiitation  of  the  leg  by  lateral 
flaps  is  not  a  popular  operation,  as  it  offers  too  much  en- 
couragement to  subsequent  protrusion  of  the  bone. 


776  A   MANUAL    OF  SURGERY. 

Amputation  just  below  the  Knee. — The  scat  of  election 
is  one  inch  below  the  tuberosities.  No  muscle  is  needed  in 
the  flap.  Cut  two  flaps  of  skin,  equal  in  size  and  semilunar 
in  shape,  these  flaps  beginning  anteriorly  two  inches  below 
the  tuberosity  of  the  tibia.  One  flap  is  antero-external  and 
the  other  is  postero-internal  (Fig.  99,  6,  7).  The  flaps  are 
pulled  up,  the  anterior  muscles  are  cut  as  high  up  as  pos- 
sible, and  the  posterior  muscles  are  cut  through  the  middle 
of  the  portion  exposed  (Bell).  The  bone  is  sawn  one  inch 
below  the  tuberosity. 

Disarticulation  of  the  Knee. — In  disarticulation  by  the 
long  anterior  flap  (Garden's  amputation ;  Fig.  97,  8),  make 
a  long  anterior  skin-flap,  incise  the  ligament  of  the  patella, 
turn  up  the  flap  with  the  patella,  open  the  joint,  and  make 
a  short  posterior  flap  by  cutting  from  within  outward  and 
downward.  The  knee  may  be  disarticulated  by  means  of  a 
long  anterior  and  a  short  posterior  flap  (Fig.  97,  6,  7). 

Amputation  through  the  Femoral  Condyles. — Syme's 
Method  by  a  Long  Posterior  Flap  (Figs.  99,  lOO,  4,  8). — Carry 
a  skin-incision  with  a  very  slight  downward  curve  from  one 
condyle  to  the  other,  across  the  middle  of  the  patella.  Cut 
down  to  the  bone,  retract  the  flap,  and  cut  the  quadriceps 
above  the  patella.  Insert  a  long  knife  at  one  angle  of  the 
wound,  pass  it  back  of  the  femur,  and  make  it  emerge  at  the 
opposite  angle,  cutting  a  posterior  flap  eight  inches  long. 
Retract  the  posterior  flap,  clear  for  sawing,  and  section  the 
condyles  horizontally. 

Amputation  of  the  Thigh. — In  thigh-amputation  in  the 
lozuer  third  either  a  flap  or  a  circular  operation  may  be  per- 
formed. In  a  double-flap  operation  a  semilunar  skin-incision 
should  be  made  from  without  inward  and  the  muscles  should 
be  cut  by  transfixion  (Fig.  187).  In  the  lower  third  Teale's 
flap  (Fig.  97,  9,  10)  or  the  long  anterior  flap  may  be  employed. 
The  amputation  by  a  long  anterior  flap  consists  in  making 


AMPUTATIONS. 


777 


Fig.  187. — Amputation  of  the  Thigh  (Bryant). 


a  lengthy  skin-flap,  reflecting  it,  cutting  the  anterior  struc- 
tures to  the  bone,  again  entering  the  long  knife  at  one  angle 
of  the  incision,  pushing  it  back  of  the  femur,  bringing  it 
out  at  the  other  angle, 
and  cutting  the  struc-  '^''  ^"^ 
tures  back  of  the  bone 
directly  backward  (Fig. 
98,16).  Bell  amputates 
by  a  long  anterior  semi- 
lunar flap  and  a  short 
posterior  flap.  In  am- 
putations in  the  nppej- 
tivo-tJiirds  of  the  thigh 
the  best  plan  is  to  mark 
out  equal  anterior  and 
posterior  semilunar 
skin-flaps,  enter  the  long  knife  at  one  angle  of  the  anterior 
flap,  bring  it  out  at  the  other  angle,  and  cut  the  muscles 
by  transfixion  (Fig.  175).  Cut  the  posterior  flap  in  the  same 
manner.  Some  surgeons  prefer  a  long  anterix)r  semilunar 
flap  and  a  short  posterior  semilunar  flap.  The  pure  circular 
is  not  adapted  to  the  thigh. 

Disarticulation  of  the  Hip -joint. — In  the  bloodless  method 
of  WyetJi  (Fig.  188)  the  band  of  the  Esmarch  apparatus  is  held 
up  by  Wyeth's  pins,  the  outer  pin  being  inserted  one  and  a 
half  inches  below  and  a  little  internal  to  the  anterior  superior 
spine  of  the  ilium,  and  brought  out  just  back  of  the  great 
trochanter.  The  inner  pin  is  entered  one  inch  below  the 
level  of  the  crotch,  internal  to  the  saphenous  opening,  and  it 
emerges  one  and  a  half  inches  in  front  of  the  tuberosity  of 
the  ischium.  The  hip  is  brought  well  over  the  edge  of  the 
table,  a  circular  incision  is  made  down  to  the  deep  fascia 
six  inches  below  the  constricting  band,  and  joined  by  a 
longitudinal  skin-cut  reaching  from  the  incision  to  the  level 


n^ 


A    MANUAL    OF  SURGERY. 


of  the  circular  incision,  and  the  cuff  is  reflected  to  the 
level  of  the  lesser  trochanter.  Cut  the  muscles  by  a  circular 
sweep  at  the  level  of  the  retracted  cuff,  open  the  capsule 
freely,  cut  the  cotyloid  ligament  posteriorly,  have  the  thigh 
bent  upward,  forward,  and  inward  to  dislocate  the  head  of 
the  bone,  and,  using  the  thigh  as  a  handle,  incise  the  round 
ligament  and  remove  the  limb.  After  ligating  the  vessels 
and  introducing  tubes  the  flaps  are  sewn  together  vertically. 


Fig.  i88. — Amputation  at  the  Hip-joint :  Wyeth's  bloodless  method 


The  old  transfixion  operation  is  practically  extinct.  A 
'^ -amputation  may  be  employed.  It  consists  of  an  external 
straight  incision  down  to  the  bone,  starting  over  the  great 
trochanter,  down  the  outer  side  of  the  limb,  and  a  circular 
incision  through  the  skin  five  inches  below  the  constricting 
band,  the  muscles  being  cut  by  a  circular  sweep  at  the  level 
of  the  retracted  skin.  This  method  affords  easy  access  to 
the  joint.  The  bloodless  method  of  Wyeth,  as  applied  to 
the  hip-joints  and  shoulder-joints,  is  one  of  the  most  notable 
modern  advances  in  the  art  of  surgery. 


BKONCHOCELE.  779 

Bronchocele,  or  Goitre. 

A  goitre  is  an  enlargement  of  the  thyroid  gland  not  due  to 
malignant  tumor  or  to  inflammation.  Goitre  may  affect  a  por- 
tion of  one  lobe,  both  lobes,  or  both  lobes  and  the  isthmus, 
and  it  may  occur  sporadically  or  endemically.  In  Switzerland 
it  is  very  common.  Among  the  alleged  causes  are  the  playing 
of  wind-instruments,  the  drinking  of  snow-water,  and  the  use 
of  water  impregnated  with  the  salts  of  lime.  Hereditar}'  influ- 
ence is  frequently  noted.  The  forms  of  goitre  are  as  follows  : 
Simple  liypcrtrophy,  a  hypertrophy  of  the  gland-tissue,  usually 
symmetrical ;  cystic  goitre,  in  which  cysts  form  in  hypertro- 
phied  glands,  or  rarely  in  non-hypertrophied  thyroids,  the 
cysts  being  either  single  or  multiple,  being  due  to  mucoid  or 
colloid  degeneration,  and  containing  a  fluid  sometimes  clear 
and  thin,  sometimes  viscid,  and  often  coffee-ground  in  charac- 
ter; and  fibrous  goitre,  a  fibrous  induration  which  is  apt  to 
arise  in  old  bronchoceles,  and  which  may  pass  into  a  calca- 
reous condition. 

The  symptoms  are — congestion  of  the  head  and  neck  from 
enlargement  of  veins;  occasionally  cerebral  symptoms  (anae- 
mia, syncope,  even  convulsions)  from  pressure  on  carotids ; 
irritation  of  recurrent  laryngeal  nerve  (causing  spasm  of 
the  glottis  or  laryngeal  paralysis) ;  compression  of  the 
trachea  (dyspnoea).  Rapidly-growing  goitres  (acute  goitres) 
are  often  fatal ;  slow-growing  goitres  are  rarely  fatal.  A 
goitre  moves  with  the  gullet  in  swallowing. 

Treatment. — Medical  treatment  of  goitre  is  of  little  use. 
Iodide  of  potassium  and  arsenic  internally  have  been  ad- 
vised ;  ointment  of  red  oxide  of  mercury  locally  is  advocated 
by  some  writers.  The  only  hopeful  methods  are  surgical. 
Cystic  goitres  may  be  aspirated  and  injected  with  a  solution 
of  iodine.  Electrolysis  may  benefit  a  soft  goitre,  the  negative 
pole  being  pushed  into  the  growth,  the  positive  pole  being 


780  A    MA A^ UAL    OF  SURGERY. 

applied  to  its  surface.  Ligation  of  the  thyroid  arteries  has 
been  recommended  by  some  surgeons.  The  radical  opera- 
tion is  the  remov^al  of  the  mass  (thyroidectomy).  It  is  a 
bloody  and  dangerous  operation,  and  during  its  performance 
and  for  a  time  after  its  completion  the  patient  is  liable  to 
sudden  and  fatal  collapse.  The  entire  gland  must  not  be 
removed  :  a  bit  of  it  is  always  allowed  to  remain,  otherwise 
cachexia  strumipriva  (or  myxcedema)  may  arise. 

Exophthalmic  or  Pulsating*  Goitre. — In  this  condition 
there  are  palpitation  of  the  heart,  rapid  pulse,  protrusion  of 
the  eyeballs,  and  enlargement  of  the  thyroid  gland.  It  is  a 
vaso-motor  ataxia  (Cohen)  resulting  from  disease  of  the 
sympathetic  system.  Von  Graefe's  sign  is  retraction  of 
the  upper  lids  and  a  failure  of  the  lids  to  follow  the  eyes 
when  looking  down.  A  systolic  bruit  can  be  heard  over 
the  goitre.  The  goitre  is  usually  bilateral,  but  may  be 
unilateral,  and  it  may  be  intermittent  or  persistent.  Emo- 
tional causes  are  influential  in  its  production.  Nystagmus, 
tremor,  flashes,  haemoptysis,  haematemesis,  and  mental  dis- 
turbances are  apt  to  occur.  Exophthalmic  goitre  may  be 
treated  by  aconite,  belladonna,  digitalis,  or  strophanthus. 
Electricity  may  be  used.  Extirpation  has  been  tried,  but 
it  is  scarcely  considered  advisable. 

XXXVII.  ASEPSIS  AND  ANTISEPSIS. 

Surgical  cleanliness  may  be  obtained  by  either  the  aseptic 
or  the  antiseptic  method.  In  the  aseptic  method  heat, 
chemical  germicides,  or  both  are  used  to  cleanse  the  instru- 
ments, the  field  of  operation,  and  the  hands  of  the  surgeon 
and  his  assistants.  After  the  incision  has  been  made  no 
chemical  germicide  is  used,  the  wound  being  simply  sponged 
with  gauze  sterilized  by  heat;  if  irrigation  is  necessary, 
boiled  water  is  used,  and  the  wound  is  dressed  with  gauze 


ASEPSIS  AXD  ANTISEPSIS.  78  I 

which  has  been  rendered  sterile  by  heat.  The  aseptic 
method  should  be  used  only  in  non-infected  areas.  The 
elimination  of  chemical  germicides  lessens  serous  flow 
and  often  enables  the  surgeon  to  dispense  with  drainage- 
tubes.  If  irrigation  is  not  practised  and  the  wound  is 
dressed  with  dry  gauze,  the  procedure  is  said  to  be  by 
the  "  dry "  method.  In  the  antiseptic  method  the  same 
preparations  are  made  for  the  operation  as  in  the  aseptic 
method,  but  during  the  operation  sponges  impregnated  with 
a  chemical  germicide  are  used,  and  the  wound  is  dressed 
with  crauze  containing-  corrosive  sublimate.  If  the  wound 
is  not  flushed  with  a  chemical  germicide,  and  is  dressed  with 
dry  gauze,  the  operation  is  said  to  be  by  the  "  dry  "  antisep- 
tic method.  The  antiseptic  method  is  always  preferred  in 
infected  areas.  Dry  dressings  are  usually  preferable  to 
moist  dressings,  because  they  are  more  absorbent  and  do 
not  act  as  poultices,  and  dry  dressings  may  be  used  even 
when  the  wound  has  been  flushed. 

Preparations  for  an  Operation. — The  surgeon  and  his 
assistants  remove  their  coats,  roll  up  their  sleeves,  and 
envelop  their  bodies  in  aseptic  or  antiseptic  sheets  to  pro- 
tect the  patient  and  themselves.  The  hands  and  forearms 
are  scrubbed  with  soap  and  hot  water.  There  is  nothing 
equal  to  the  ethereal  soap  of  Johnson,  which  is  a  solution 
of  castile  soap  in  ether.  The  brush  employed  is  kept 
constantly  in  a  i  :  lOOO  solution  of  corrosive  sublimate. 
The  nails  are  cut  short,  are  cleansed  with  a  knife,  and  the 
hands  are  again  scrubbed.  The  hands  are  dipped  in  a 
hot  solution  of  corrosive  sublimate,  and  with  the  fore- 
arms are  scrubbed  for  at  least  a  minute,  the  nails  receiving 
especial  care ;  they  are  then  dipped  for  one  minute  into  pure 
alcohol  and  are  again  bathed  with  .the  mercurial  solution. 
Kelly  disinfects  the  hands  by  washing  them  with  soap  and 
water,  dipping  them  in  a  solution  of  permanganate  of  potas- 


782  A  maniTal  of  surgery. 

slum  (a  saturated  solution  in  boiling  distilled  water),  and 
decolorizing  them  in  a  saturated  solution  of  oxalic  acid. 

Instruments  are  disinfected  by  boiling  for  fifteen  minutes 
in  a  I  per  cent,  solution  of  carbonate  of  sodium  and  then 
rinsing  them  in  a  5  per  cent,  solution  of  carbolic  acid.  They 
are  kept  in  trays  containing  boiled  water.  Instruments  can  be 
disinfected  satisfactorily  by  keeping  them  for  fifteen  minutes 
in  a  5  per  cent,  solution  of  carbolic  acid.  Instruments  with 
handles  of  wood  must  not  be  boiled,  but  they  are  disinfected 
by  carbolic  acid.  After  the  completion  of  the  operation  the 
instruments  should  be  scrubbed  with  soap  and  water,  boiled, 
and  dried.  Marine  sponges  are  rarely  used,  small  pieces  of 
sterilized  or  antiseptic  gauze  being  preferred.  In  the  abdo- 
men Ashton's  aseptic  gauze  pads  are  employed.  These  pads 
are  about  ten  inches  square,  and  are  made  of  a  number  of 
folds  of  gauze  stitched  loosely  at  the  edges.  Whenever 
possible,  give  the  patient  some  days'  rest  in  bed  before  a 
severe  operation,  and  place  him  on  a  diet  nutritious  but  not 
bulky.  The  night  before  the  operation  give  a  saline  cathartic, 
and  the  morning  of  the  operation  employ  an  enema.  When- 
ever possible,  give  a  general  warm  bath  the  day  before.  The 
evening  before  the  operation  scrub  the  entire  field  and  well 
clear  of  it  with  soap  and  water,  shave  if  necessary,  wash 
with  ether,  scrub  well  with  hot  corrosive-sublimate  solution 
(i  :  1000),  apply  a  layer  of  moist  corrosive-sublimate  gauze, 
and  place  over  this  dry  antiseptic  gauze,  a  rubber  dam,  and 
a  bandage.  On  removing  the  dressings  to  perform  the 
operation,  scrub  the  part  again  with  hot  mercurial  solution. 
In  emergency  cases  disinfection  must  be  practised  just  pre- 
vious to  the  operation. 

The  favorite  ligature  material  is  catgut,  which  is  well  pre- 
pared by  boiling  in  alcohol.  Another  method  is  to  take  the 
raw  catgut,  soak  it  in  ether  for  twenty-four  hours,  soak  it 
for  twenty-four  hours  in  an  alcoholic  solution  of  corrosive 


ASEPSIS  AND   ANTISEPSIS. 


783 


sublimate  (i  :  500),  wind  it  on  sterilized  glass  rods,  and 
place  it  for  keeping  in  ether  or  in  alcohol.  Fowler's  cat- 
gut is  carried  in  tubes  of  alcohol  hermetically  sealed,  each 
tube  holding  twelve  ligatures.  Johnson's  quick  method  of 
preparing  catgut  is  as  follows  :  Place  it  for  twenty-four  hours 
in  ether ;  at  the  end  of  this  period  place  it  in  a  solution  con- 
taining 20  grains  of  corrosive  sublimate,  lOO  grains  of  tartaric 
acid,  and  6  ounces  of  alcohol.  The  small  gut  is  kept  in  this 
for  ten  or  fifteen  minutes,  the  larger  gut  from  twenty  to  thirty 
minutes,  but  never  longer.  It  is  placed  for  keeping  in  a  mix- 
ture containing  I  drop  of  chloride  of  palladium  to  8  ounces 
of  alcohol.  This  gut  is  strong  and  reliable.  At  the  time  of 
operation  the  gut  is  placed  in  a  solution  two-thirds  of  which 
is  5  per  cent,  carbolic-acid  solution  and  one-third  of  which 
is  alcohol.  Chromicized  gut  will  not  be  absorbed  so  readily 
as  other  gut.  It  is  prepared  by  adding  200  parts  by 
weight  of  catgut  to  200  parts  of  carbolic  acid,  2000  parts 
of  water,  and  i  part  of  chromic  acid.  After  remaining 
in  this  solution  twenty-four  hours  it  is  transferred  for 
permanent  keeping  to  ether  or  to  alcohol.  Sutures  of  silk 
should  be  well  boiled  before  using.  A  convenient  method 
of  preparation  is  to  wind  the  silk  on  a  glass  spool,  place 
the  spool  in  a  large  test-tube,  close  the  mouth  of  the  tube 
with  absorbent  cotton,  introduce  the  tube  into  a  steam 
sterilizer,  and  keep  it  there  for  one  hour.  These  tubes  are 
carried  in  wooden  boxes  sealed  with  rubber  corks.  Silk- 
worm gut  is  prepared  by  placing  it  in  ether  for  forty-eight 
hours  and  in  a  solution  of  corrosive  sublimate  (i  :  looo)  for 
one  hour.  It  is  carried  in  a  long  tube  filled  with  alcohol. 
A  few  minutes  before  using,  the  gut  is  placed  in  carbolic 
acid  and  alcohol  (two-thirds  of  a  5  per  cent,  solution  of  acid, 
one-third  of  alcohol).     Silver  ivire  is  prepared  by  boiling. 

Dressings  are  made  of  cheese-cloth.     This  cloth  is  boiled 
in  a  solution  of  carbonate  of  soda,  rinsed  out,  and  dried; 


784  ^   MANUAL    OF  SURGERY. 

it  is  then  soaked  for  twenty-four  hours  in  a  solution  contain- 
ing I  part  of  corrosive  subhmate,  2  parts  of  table-salt,  and 
500  parts  of  water.  It  is  kept  in  jars,  and  it  may  be  main- 
tained moist  or  dry. 

Sterilized  gauze  is  prepared  by  boiling  the  material  in  soda, 
rinsing,  and  either  boiling  it  for  fifteen  minutes  or  placing  it 
in  the  steam  sterilizer  for  the  same  time. 

Iodoform  gauze  is  useful  for  packing  and  for  dressing  foul 
wounds.  It  is  prepared  as  follows  :  Make  an  emulsion  com- 
posed of  equal  quantities  by  weight  of  iodoform,  glycerin, 
and  alcohol,  and  add  corrosive  sublimate  in  the  proportion  of 
I  part  to  the  lOOO  of  the  mixture.  This  mixture  stands  for 
three  days.  Take  moist  bichloride  gauze,  saturate  it  with 
the  emulsion,  let  it  drip  for  a  time,  and  keep  it  in  sterilized 
and  covered  glass  jars  (Johnson).  Lister's  cyanide  gauze 
(double  cyanide  of  zinc  and  mercury)  must  be  dipped  into 
a  corrosive-sublimate  solution  (i  :  2000)  before  using.  All 
antiseptic  appliances  can  be  bought  ready  prepared  from 
reliable  firms.  Small  wounds  in  which  drainage  is  not  em- 
ployed may  often  be  dressed  by  laying  a  film  of  aseptic  ab- 
sorbent cotton  over  the  wound  and  applying,  by  means  of  a 
clean  camel's-hair  brush,  iodoform  collodion  (grs.  xlviij  to  Ij). 

When  a  wound  is  dressed  with  gauze  a  rubber  dam  must 
always  be  laid  over  the  dressings,  so  as  to  diffuse  the  dis- 
charge and  prevent  it  from  coming  rapidly  to  the  surface. 
Drainage  is  obtained  when  needed  by  rubber  tubes  or  by 
strands  of  horsehair,  silkworm  gut,  or  catgut,  but  these 
three  last-named  materials  will  not  drain  off  pus.  Dressings 
must  be  changed  as  soon  as  soaking  is  apparent.  Stitches 
may  usually  come  out  about  the  sixth  day.  In  large  wounds 
only  a  portion  of  them  are  taken  out  at  one  time,  the  balance 
being  allowed  to  remain  for  a  couple  of  days  longer.  When 
a  stitch  begins  to  cut  it  is  doing  no  good,  and  it  should  be 
removed,  no  matter  how  short  a  time  it  has  been  in  place. 


ASEPSIS  AXD  ANTISEPSIS.  785 

Preparation  of  Marine  Sponges. — ^Beat  out  the  dust ;  place 
them  for  forty-eight  hours  in  a  solution  of  hydrochloric  acid 
(15  per  cent.);  wash  them  out  with  water;  place  them  for 
one  hour  in  a  solution  of  permanganate  of  potassium  (siij  to 
5  pints  of  water);  soak  for  four  hours  in  a  solution  contain- 
ing 10  ounces  of  hyposulphite  of  sodium,  5  ounces  of  hydro- 
chloric acid,  and  3  pints  of  water ;  wash  with  running  water 
for  six  hours.  Keep  the  sponges  in  a  jar  containing  corro- 
sive-sublimate solution  (i  :  1000).  After  using,  wash  in  hot 
water,  soak  for  half  an  hour  in  a  solution  of  sodium  carbonate 
(i  :  32),  wash  in  hot  water,  and  replace  in  corrosive  sublimate. 
A  marine  sponge  inevitably  becomes  foul  in  its  interior,  and 
should  not  be  used. 

To  clean  the  vagijia  or  rectum,  use  a  sponge  soaked  with 
creolin  and  Johnson's  ethereal  soap  (i  :  16),  and  subsequently 
irrigate  with  corrosive-sublimate  solution. 

Semis  Decalcified  Bone-chips. — Take  the  shaft  of  the  tibia 
or  femur  of  a  recently  killed  ox,  saw  it  into  portions  two 
inches  in  length,  remove  the  marrow  and  periosteum,  and 
place  the  bits  of  bone  in  a  15  per  cent,  solution  of  hydro- 
chloric acid.  Change  the  solution  every  twenty-four  hours. 
In  from  two  to  four  weeks  the  bone  will  be  decalcified. 
Wash  in  distilled  water,  place  the  bone  in  a  dilute  solution 
of  potash  to  neutralize  the  acid,  and  then  immerse  for 
twenty-four  hours  in  distilled  water.  The  portions  of  bone 
are  now  cut  into  strips  in  the  direction  of  the  long  axis  of 
the  segments,  each  strip  being  three-quarters  of  an  inch 
wide  and  being  sliced  up  into  bits  one  millimetre  thick. 
These  chips  are  kept  in  an  alcoholic  solution  of  corrosive 
sublimate  (i  :  500). 

50 


INDEX. 


Abbe's  catgut  ring,  638 

method  of  intestinal  anastomosis,  638 
string  saw,  613 
Abdomen,  diseases  of,  606 
injuries  of,  606 
operations  upon,  629 
Abdominal  section,  629 

bleeding  in,  253 

for  appendicitis,  631 
wall,  contusion  of,  606 

gunshot  wound  of,  610 

penetrating  wound  of,  610 

wounds  of,  610 
Abscess,  acute,  90,  91 

appendicinal,  92,  622,  625 

Brodie's,  298 

cerebral,  from  ear  disease,  559 

chronic,  97 

cold,  97 

of  lymphatic  glands,  99 
dorsal,  98 
extradural,  559 
forms  of,  90 
gluteal,  403 
iliac,  99 

ischio-rectal,  662 
lumbar,  99,  403 
lymphatic,  97 
mediastinal,  93 
metastatic,  123,  128 
of  antrum  of  Highmore,  93,  5S3,  584 
of  bone,  298 
of  the  brain,  556 
of  the  cerebelkim,  566 
of  the  hip,  403 
of  the  kidney,  705 
of  the  larynx,  93 
of  the  liver,  92 
of  the  lung,  93 
of  the  maxillary  antrum,  584 
of  the  prostate  gland,  93,  748 


Abscess  of  the  scalp,  534 

of  the  temporo-sphenoidal  lobe,  565 

Paget's,  91 

palmar,  511 

perinephric,  93,  706 

psoas,  99,  403 

residual,  91,  144 

retro-pharyngeal,  93,  98 

scrofulous,  97 

tubercular,  90,  97,  142 
Abscesses,  88 

Acid,  carbolic,  as  an  antiseptic,  782 
Actinomyces,  164 
Actinomycosis,  19,  164 
Acupressure  in  aneurysm,  240 
Adams's  operation,  474 
Adenitis,  chronic,  684 

tuberculous,  144 
Adenomata,  216 

cystic,  217 
Adhesions,  426 
Agnew's  operation  for  webbed  fingers, 

520 
Air-passages,  foreign  bodies  in,  585 
Alcohohc  unconsciousness,  541 
Aleppo  boils,  680 

Alimentary'  canal,  foreign  bodies  in,  611 
Allis's  ether-inhaler,  669 

signs,  374 
Alopecia  of  syphilis,  176 
Amputation,  761 

a  la  manchette,  765 

at  ankle-joint,  773 

Pirogofif's  method,  774 
Syme's  method,  773 

at  elbow-joint,  769 

at  hip-joint,  777 

Wyeth's  method,  777 

at  metacarpo-phalangeal  joints,  768 

at  shoulder-joint,  770 
Dupuytren's  method,  771 

787 


788 


INDEX. 


Amputation  at  shoulder-joint,  Larrey's 
method,  770 

Lisfranc's  method,  771 
at  wrist-joint,  768 
Chopart's,  773 
circular,  764 

modified,  765 
elliptical  method,  765 
flap  method,  766 
for  aneurysm,  240 
for  gangrene,  121 
intermediate,  761 
methods  of,  764 
modified  circular  method,  765 
of  arm,  770 
of  fingers,  767 

distal  phalanx  of,  767 

middle  phalanx  of,  768 

proximal  phalanx  of,  768 
of  foot,  771 

Chopart's  method,  773 

Forbes's  method,  773 

Hey's  method,  773 

Lisfranc's  method,  771 
of  forearm,  769 

Teale's  operation,  769 
of  hand,  767 
of  leg,  774 

below  the  knee,  776 

Garden's  method,  776 

lateral  flaps,  775 

long  anterior  flap,  774 

long  posterior  and   short  anterior 
flap,  775 

modified  circular,  775 

rectangular  flaps,  774 

S6dillot's  method,  774 

Syme's  method,  776 

through  the  femoral  condyles,  776 

through  the  knee-joint,  776 
of  penis,  755 
of  thigh,  776 

Teale's  flaps  in,  776 
of  toes,  771 
oval  method,  766 
primary,  761 
racket  method,  776 
secondary,  761 
T-shape  of,  766 

through  middle  tarsal  joint,  773 
Wyeth's  bloodless,  of  hip-joint,  777 
Wyeth's  pins  in,  764 
Amputations,  special,  767 


Amylene,  666 

Amyloid  degeneration,  404 

Anaesthesia,  666 

general,  666 

local,  673 

preparations  for,  666,  667 

primary,  673 

treatment  of  complications  in,  671 
Anaesthetic  state  from  chloroform,  670 

from  ether,  670 
Anaesthetics,  666 

general,  666 

local,  666 
Anastomosis,  intestinal,  637 
with  rings,  637 
without  rings,  638 
Anastomosis-rings,  637 
Anderson's  method  of  tendon-lengthen- 
ing, 517 
Aneurysm,  229 

acupressure  in,  240 

acute,  230 

amputation  for,  240 

arterio-venous,  230,  241 

by  anastomosis,  230,  242 

capillary,  231 

circumscribed,  231 

cirsoid,  209,  231,  242 

consecutive,  230 

cylindrical,  231 

diffused,  244 

dissecting,  230 

distal  ligation  in,  239 

embolic,  231 

false,  229 

forms  of,  230 

fusiform,  230 

miliary,  231 

of  bone,  231 

operation  for,  Anel's,  237 
Antyllus's,  237 
Brasdors,  239 
Hunter's,  238 
Wardrop's,  239 

operative  treatment  of,  237 

sacculated,  230 

secondary,  231 

spontaneous,  231 

traumatic,  230-240 

treatment  of,  by  ligature,  237 

true,  229 

verminous,  231 
Angeiomata,  208 


INDEX. 


789 


Angeiomata,  capillary,  208 

cavernous,  209 

plexiform,  209 

simple,  208 
Ankle-joint  disease,  409 

osteoplastic  resection  in,  409 
Syme's  amputation  in,  409 
Ankylosis,  425 

bony,  426 

extra-articular,  428 

false,  428 

fibrous,  426 

intra-articular,  425 

osseous,  426 

true,  426 
Antagonistic  microbes,  30 
Anthrax,  160 

benign,  680 

forms  of,  160 
Antisepsis,  780 

Antiseptic  surgical  cleanliness,  780 
Antitoxine  of  tetanus,  137 
Antitoxines,  27 
Antrum  of  Highmore,  inflammation  of, 

583 

injuries  of,  583 
Anus,  diseases  of,  654 

fissure  of,  665 

injuries  of,  654 

prolapse  of,  658 

pruritus  of,  665 
Apoplexy,  540 
Appendicitis,  620 

abdominal  section  for,  631 

bacterium  coli  commune  a  cause  of, 
621,  622 

catarrhal,  622,  623 

caused  by  foreign  bodies,  622 
by  scybalae,  621,  622 

cellulitis  in,  622 

etiology  of,  621 

gangrenous,  623,  624 

local,  peritonitis  in,  622 

obliterative,  623 

operation  for,  63 1 

pathology  of,  621 

perforation  in,  622-624 

recurrent,  623 

septic  peritonitis  in,  622 

simple  parietal,  623 

stercoral,  622 

suppurative,  624 

symptoms  of,  624 


Appendicitis,  traumatic,  622 

treatment  of,  625 
Appendicular  abscess,  92,  622-625 

colic,  622-624 
Arachnitis,  551 
Ardor  urinse,  747 
Areas,  motor,  533,  534 
Arterial  piles,  656 

rupture  with  fracture,  326 

sclerosis,  228 

transfusion,  265 
Arteries,  calcification  of,  228 

inflammation  of,  227 

ligation  of.     See  Ligation. 

wounds  of,  243 
Arteritis,  acute,  227 

chronic,  228 

obliterative,  228 

syphilitic,  178,  228 
Arthrectomy,  481,  482 

of  knee-joint,  482 
Arthritis,  397 

deformans,  416 

gonorrhoeal,  412 

gouty,  415 

infective,  411 

neuropathic,  419 

rheumatic,  414 

septic,  411 

tubercular,  398 
Arthropathie  des  ataxiques,  431 
Arthropathy,  tabetic,  419 
Articular  injuries,  422 

wounds,  422 
Artificial  respiration  in  anaesthesia,  672 
Asepsis,  780 
Aseptic  gauze,  784 

surgical  cleanliness,  780 

wounds,  149 
Aspiration  of  bladder,  713 

of  joints,  480 
Aspirator,  pneumatic,  480 
Atheroma,  228 
Atony  of  bladder,  716 
Atrophy  of  bone,  295 

of  muscles,  505 
Auto-suggestion,  577 

Bacillus,  20 
mallei,  33 
of  anthrax,  33 
of  glanders,  33 
of  gonorrhoea,  32 


790 


INDEX. 


Bacillus  of  Koch,  32 
of  Lustgarten,  33 
of  malignant  oedema,  t^2> 
of  Neisser,  32 
of  Nicolaier,  32 
of  syphilis,  33 
of  tetanus,  32 
of  tubercle,  32,  138,  139 
pyocyaneus,  31 
Bacteria,  17-19 
distribution  of,  24 
effects  of  heat  and  cold  upon,  23 
life-conditions  of,  22 
motile,  17 

multiplication  of,  21 
pathogenic,  19 
Bacteriology,  17 
Bacterium  coli  commune  of  Escherich, 

621,  622 
Balanitis,  748 
Balano-posthitis,  748 
Bandage,  anterior  figure-of-8,  of  shoul- 
ders, 690 
Barton's,  689 
Borsch's,  of  eye,  688 
circular,  685 
crossed,  of  angle  of  jaw,  689 

of  eye,  688 
demi-gauntlet,  686 
Desault's,  691 
Esmarch's,  762 
gauntlet,  686 
Gibson's,  689 
handkerchief,  692 
oblique,  of  jaw,  689 
of  elbow,  690 
of  foot  covering  heel,  687 
not  covering  heel,  687 
of  neck  and  axilla,  690 
posterior  figure-of-8,  of  the  shoulder, 

690 
recurrent,  of  head,  692 

of  stump,  692 
Kibble's,  688 
spica,  of  groin,  690 
of  instep,  688 
of  shoulder,  690 
spiral,  685 

of  fingers,  686 
reversed,  685 

of  lower  extremity,  687 
of  upper  extremity,  686 
T,  of  perineum,  692 


Bandage,  Velpeau's,  350,  390 
Bandages,  685 
Barton's  bandage,  689 
Bassini's  operation  for  femoral  hernia, 
646 
for  inguinal  hernia,  646 
Bed-sores,  107,  120 
Bees,  stings  of,  157 
Bent  tibia,  osteotomy  for,  473 
Bichat's  fissure,  530 
Bigelow's  operation  for  vesical  calculi, 

730 
Bigg's  apparatus  for  bunions,  515 
Bites  of  insects  and  reptiles,  157,  158 

of  snakes,  159 
Bladder,  aspiration  of,  713 

atony  of,  716 

contusion  of,  714 

extraperitoneal  rupture  of,  715,  716 

female,  growths  in,  736 

injuries  of,  714 

intraperitoneal  rupture  of,  715,  716 

operations  on,  726 

rupture  of,  715,  716 

stone  in,  717 

tumors  of,  725 
Blastomycetes,  18 
Bleeding  from  kidney-substanct,  697 

from  pelvis  of  kidney,  697 

from  ureter,  697 

to  death,  250 
Blind  boil,  679 
Blood,  tests  for,  696 

transfusion  of,  263 
Boils,  679 

endemic,  of  tropics,  680 
Bond's  splint,  369 
Bone,  abscess  of,  298 

aneur)'sm,  231 

atrophy  of,  295 

hypertrophy  of,  295 

inflammation  of,  295 

plates  of  Senn,  638 

transplantation  of,  477 
Bone-chips,  Senn's  decalcified,  785 

in  treatment  of  necrosis,  303 
Bone -felon,  512 
Bone-grafting,  477 
Bones,  diseases  of,  295 

excision  of,  481 
open  method,  481 
subperiosteal  method,  48 1 

injuries  of,  295 


INDEX. 


791 


Bones  of  skull,  diseases  of,  535 
malformations  of,  535 

operations  on,  470 
Borsch's  eye-bandage,  688 
Bougie,  tiliform,  752 

oespphageal,  604 
Bowel-obstruction,  613 
Bow-legs,  521 
Brain,  abscess  of,  556 

compression  of,  540 

concussion  of,  538 

disease  of,  from  ear  disease,  558 

hernia  of,  551 

inflammation  of,  551 

lacerations  of,  538 

malformations  of,  536 

operations  on,  562 
technique  of,  564 

traumatic  inflammation  of,  551 

tuberculosis  of,  144 

tumor  of,  557 

water  on,  553 

wounds  of,  549 
Broca's  regional  terms,  530 
Brodie's  abscess,  298 

joint,  420 
Bromide  of  ethyl,  666 
Bronchocele,  779 
Bruises.     See  Conttisions. 

perineal,  736 
Bryant's  triangle,  375 
Bubo  of  chancroid,  753 

of  gonorrhoea,  748 

syphilitic,  171 
Bunion,  514 
Burns,  675 
Bursse,  diseases  of,  503 

injuries  of,  503 
Bursitis,  513 
Button,  Murphy's,  639 

Calculi,  renal,  703 

Calculus,  vesical,  717 
crushing  of,  730 
lateral  lithotomy  for,  726 
suprapubic  lithotomy  for,  728 

Calyx-eyed  needle,  632,  638 

Cancer.     See  Carcinomata. 

Cancrum  oris,  118 

Caput  succedaneum,  527 

Carbuncle,  680 

Carcinoma  of  -stomach,  61 1 

Carcinomata,  217 


Carcinomata,  adenoid,  221 

classification  of,  218 

colloid,  221 

cylindrical-celled,  219,  221 

encephaloid,  219,220 

glandular,  221 

hematoid,  220 

melanotic,  220 

of  oesophagus,  603 

of  penis,  754 

of  rectum,  661 

scirrhous,  661 

spheroidal-celled,  218,  220 

squamous-celled,  218 

telangiectatic,  220 
Carden's  amputation,  776 
Caries,  296,  299,  579 

cervical  dyspnoea  in,  574 

in  wrist-joint  disease,  411 

necrotica,  299 

sicca  in  shoulder-joint  disease,  410 

spinal,  403 

strumous,  296-299 

torticollis  in,  574 
Cartilages,  floating,  200,  428 
Castration,  758 
Catarrh,  venereal,  743 
Catgut,  chromicized,  preparation  of,  783 

preparation  of,  782 
Cauter)%  actual,  in  treatment  of  hemor- 
rhage, 248 
Cell-division,  76 
CelluHtis,  132 

diffused,  87 
Cementome,  202 
Cephalhaematoma,  537 
Cephalodynia,  504 
Cerebellitis,  551 
Cerebellum,  abscess  of,  566 
Cerebral  abscess,  556 

fungus,  551 

hemorrhage,  542,  544 

irritability,  539 
Cerebritis,  551 
Cerebro-spinal  fluid,  flow  of,  in  fracture 

of  base  of  skull,  547 
Chalk-stone,  416 
Chancre,  hard,  168 

mixed  infection  of,  168 

soft,  752 
Chancroid,  752 

mixed  infection  of,  168 
Charcot's  disease,  419 


792 


INDEX. 


Charcot's  joint,  419,  431 
Chest,  contusions  of,  594 

diseases  of,  593 

injuries  of,  593 

wounds  of,  594 
Cheyne's  operation  for  femoral  hernia, 

646 
Chiene's  method  for  finding  fissure  of 

Rolando,  531,  533 
Chilblain,  677 
Choked  disk,  677 
Chloroform,  666 

administration  of,  668 
Chondromata,  199,  200 
Chondrosarcoma,  211 
Chopart's  amputation,  773 

line  of  amputation  of  foot,  772,  773 
Chordee,  743 
Choroiditis,  disseminated,   in    syphilis, 

177 
Chromicized  catgut,  783 
Chronic  arteritis,  228 
Cicatricial  stenosis  of  orifices  of  stom- 
ach, 612 
Circumcision,  754 
Cirsoid  aneurysms,  209,  231,  242 
Clap,  743 

"  Claret-stains  "  of  skin,  208,  209 
Clavus,  681 
Cleansing  of  rectum,  785 

of  vagina,  785 
Cleft  palate,  597 

operation  for,  599 
Cloaca,  302 
Clove-hitch,  435 
Clover  crutch,  727 
Club-foot,  521 
Coagulation  necrosis,  128 

in  tubercle,  139 
Cocaine  hydrochlorate,  666,  674 
Cocaine-poisoning,  674 
Cocci,  20 

of  suppuration,  31 

pyogenic,  20 
Coccidium  oviforme,  194 
Cock's  method  of  perineal  section,  740, 

752 
Coeliotomy,  629 

Cohnheim's  theory  of  tumors,  193 
Coin -catcher,  605 
Cold,  effects  of,  677 
Colic,  appendicular,  622,  624 
Collapse  from  hemorrhage,  251 


Colles's  fracture,  368 

law,  188 
Coma,  diabetic,  542 

due  to  brain  injury,  540 

hysterical,  541 

of  alcoholic  intoxication,  540 

of  opium-poisoning,  540 

post-epileptic,  541 

ursemic,  540 
Compression  of  brain,  540 

of  spinal  cord,  580 
Concussion  of  brain,  538 

of  spinal  cord,  579 
Condylomata,  175 
Congenital  hernia,  653,  654 

hydrocele,  759 

phimosis,  754 

wry-neck,  518 
Constriction  of  cardiac  orifice  of  stom- 
ach, 612 

of  pyloric  orifice,  612 
Contraction,  Dupuytren's,  519 

of  muscles,  509 
Contused  wounds,  149 

of  arteries,  243 
Contusions,  148 

of  abdominal  wall,  606 

of  bladder,  714 

of  chest,  594 

of  head,  538 

of  muscles,  507 

of  nerves,  527 

of  spinal  cord,  579 
Corns,  681 
Coxalgia,  400 
Coxarius,  morbus,  400 
Craniectomy,  535 

Cranio-cerebral  topography,  530,  534 
Cripp's  operation,  661 
Crushing  of  vesical  calculi,  730 
Cuneiform  osteotomy,  471 
Curvature  of  spine,  568 
Cushing's  suture,  632 
Cutaneous  horns,  215 
Cyrtometer,  532 

Horsley's,  533 
Cystic -adenomata,  217 

multilocular  tumors,  201 
Cystitis,  722 
Cystocele,  641 
Cystotomy,  735 
Cysts,  191 

dentigerous,  202 


INDEX. 


793 


Cysts  of  spine,  567 
Czerny-Lembeit  suture,  632 
Czerny's  method    of  tendon-lengthen- 
ing, 517 

Dactylitis,  190 

Deafness,  syphilitic,  190 

Decubitus,  120 

Deformities  of  spine,  congenital,  566 

Degeneration  of  muscles,  506 

reactions  of,  524 
Dentigerous  cysts,  202 
Derangement,  internal,  of  knee-joint, 

464 
Dermatitis  venenata,  678 
Desault's  apparatus,  350,  691 

sign  of  fracture  of  hip,  374 
Diapedesis,  37 
Diaphragmatic  hernia,  654 
Diarrhoea  of  constipation,  618 
Diastasis,  310 

Dickson's  theory  of  amyloid  degenera- 
tion, 404 
Diday's  operation  for  webbed  fingers, 

520 
Digestive  tract,  diseases  of,  597 

injuries  of,  597 
Digits,  supernumerary,  520 
Diphtheria,  tracheotomy  in,  591 
Diplococci,  20 
Direct  cell-division,  76 
Disarticulation  at  ankle-joint,  773 

at  elbow-joint,  769 

at  hip-joint,  777 

at  knee-joint,  776 

at  metacarpo-phalangeal  joint,  768 

at  shoulder-joint,  769 

at  wrist-joint,  768 
Disinfection  of  hands,  781 

of  instruments,  782 

of  patient,  782 
Dislocation,  429 

anomalous,  of  hip,  462 

axillary,  441 

bilateral,  430 

complete,  430 

complicated,  430 

compound,  430 
traumatic,  435 

congenital,  431 

consecutive,  431 

deformity  in,  433 

double,  430 


Dislocation,  habitual,  430 
incomplete,  430 
of  ankle-joint,  466 
of  astragalus,  468 
of  carpus,  454 
of  clavicle,  438-440 

acromial  end,  440 

sternal  end,  438 
of  costal  cartilages,  456 
of  elbow-joint,  448 
of  femur,  457 

downward  into  obturator  foramen, 
461 

into  pubes,  462 

into  sciatic  notch,  460 

on  to  dorsum  of  ilium,  457 

supraspinous,  462 
of  fibula,  465 
of  hip,  anomalous,  462 
of  humerus,  441 
of  inferior  radio-ulnar   articulation, 

453 
of  knee,  463 

of  knee-joint,  463,  464 

of  lower  jaw,  436 

of  metacarpal  bones,  454 

of  metacarpo-phalangeal  articulation, 

.  .454 

joint  of  the  thumb,  454 
of  metatarsal  bones,  470 
of  Monteggia,  462 
of  pelvis,  456 
of  phalanges  of  fingers,  455 

of  toes,  470 
of  radius,  451 
of  ribs,  456 

of  semilunar  cartilages  of  knee,  464 
of  shoulder-joint,  441 

reduction  of,  by  manipulation,  444 
by  extension,  445 
of  spine,  580 
of  sternum,  456 
of  superior  tibio-fibular  articulation, 

465 
of  tarsal  bones,  470 
of  tendons,  509 
of  ulna,  450 
of  wrist,  452 
old,  430 

traumatic,  436 
partial,  430 
pathological,  430,  431 
primitive,  430 


794 


INDEX. 


Dislocation,  recent,  430 

relapsing,  430 

secondary,  430 

simple,  430 

single,  430 

spontaneous,  430,  431 

subastragaloid,  469 

subclavicular,  442 

subcoracoid,  441 

subglenoid,  441 

subspinous,  442 

traumatic,  430,  431,  436 
special,  436 

unilateral,  430 

with  fracture,  325 
Displacement  in  plastic  surgery,  693 
Dugas's  sign,  442 

Dupuytren's   amputation   of  shoulder- 
joint,  771 

classification  of  burns,  675 

contraction,  519 

fracture,  466 

splint,  391 

suture,  632,  638 

Ear  disease  as  a  cause  of  cerebral  ab- 
scess, 559 
Ecchondroses,  200 
Ecchymosis,  148 
Eczematous  urethritis,  742 
Effusion  of  lymph,  82 

pleuritic,  593 
Elbow,  miner's,  5 14 
Elbow-jonit,  disarticulation  at,  769 

disease,  410 
Elephantiasis,  684 
Embolic  aneurysm,  231 
Embolism,  122,  123 

fat,  124 
Emphysema,  gangrenous,  157 
Empyema,  593 
Encephalitis,  551,  556 
Encephalocele,  536 
Encephaloid  cancer,  219,  220 
Enchrondromata,  199 
Encysted  hydrocele  of  cord,  759 

inguinal  hernia,  653 
Endarteritis,    obliterative,   in    syphilis, 

178 
Engorgement  of  retention  of  urine,  711 
Enterectomy,  61 1,  636 

with  circular  suturing,  636 
Enterocele,  641 


Entero-epiplocele,  641 
Enteroliths  in  obstructed  bowel,  614 
Enterorrhaphy,  632 
Entero-stenosis,  613 
Epididymitis,  748,  758 
Epilepsy,  operative  treatment  of,  561 
Epiphyseal  separation,  310 
of  great  trochanter,  381 
of  humerus,  358,  362 
of  lower  end  of  femur,  385 
of  lower  end  of  tibia,  390 
of  radius,  370 
of  upper  end  of  tibia,  389 
Epiphysitis,  acute,  304 
Epiplocele,  641 
Epispadias,  752 
Epistaxis,  254 
Epithelial  odontomes,  201 
Epithelioma,  218,  219 
Epulides,  fibrous,  198 

sarcomatous,  198 
Epulis,  fibrous,  198 
Equinia,  163 
Equino-varus,  522 
Erasion  of  joints,  481,  482 

of  knee-joint,  482 
Erysipelas,  129 

cellulo-cutaneous,  131 
clinical  forms  of,  130 
cutaneous,  130 
phlegmonous,  13 1 
streptococcus  pyogenes  in,  129 
Erythema  of  syphihs,  173 
Esmarch's  bandage,  762 
interrupted  splint,  490 
Estlander's  operation,  500,  596 
Ether,  administration  of,  669 

and    chloroform,  relative   merits    of, 
667,  668 
Ether-spray,  666 
Ethyl  bromide,  666 

chloride,  666 
Excision  in  shoulder-joint  disease,  410 
in  wrist-joint  disease,  411 
of  ankle-joint,  495 

Hancock's  method  in,  495 
of  astragalus,  497 

operation     for,     by     subperiosteal 
method,  497 
of  bones,  open  method,  481 
subperiosteal  method,  481 
of  clavicle,  498 
of  elbow-joint,  487 


INDEX. 


795 


Excision  of  hip-joint,  491 

anterior  excision  in,  492 

incision  of  Gross  in,  493 

lateral  operation,  492 
of  internal  hemorrhoids,  657 
of  joints,  481 

open  method,  481 

subperiosteal  method,  481 
of  knee-joint,  493 

anterior  semilunar  flap,  493 
of  metacarpal  bones,  490 
of  metatarsal   bone  of  the    big  toe, 

498 

of  riietatarso-phalangeal    articulation 
of  big  toe,  497 

of  oesophagus,  605 

of  one-half  of  lower  jaw,  502 

of  OS  calcis,  394,  496 

of  phalanges,  490 

of  pylorus,  634 

of  rectum,  661 

of  ribs,  499 
.     of  shoulder-joint,  483-486 

of  testicle,  758 

of  tongue,  602 

of  upper  jaw,  complete,  500 

of  wrist-joint,  487 

Lister's  open  method,  488 
Exfoliation,  301 
Exophthalmic  goitre,  780 
Exostosis,  201 

Exploratory  laparotomy,  620 
Extradural  abscess,  559 
Extramedullar)-  hemorrhage,  580 
Extravasation  of  urine,  716 

Farcy,  163 
Fatty  tumor,  196 
Felon,  512 

bone-,  513 

deep,  513 

superficial,  513 
Femoral  hernia,  646,  654 
Femur,  osteotomy  through  neck  of,  473 
Fergusson's  operation  for  cleft   palate, 

600 
Fever,  151 

aseptic,  80 

asthenic,  78 

hemorrhagic,  245 

nervous,  79 

primary  wound-,  80 

secondary  wound-,  81 


Fever,  sthenic,  78 
suppurative,  81 
surgical,  77,  80 
traumatic,  80 
tj-pes  of,  78 
urethral,  751 
Fibroid  tumor  of  uterus,  205 

recuiTent,  213,  214 
Fibro-adenoma,  217 
Fibromata,  soft,  197 
Fibromyoma,  205 
Fibro-myomata,  198 
Fibro-sarcoma,  211 
Fibrosum,  molluscum,  198,  207 
Filaria  sanguinis  hominis,  684 
Filiform  bougie,  752 
Fingers,  amputation  of,  767 

webbed,  520 
Fission  of  cells,  21 
Fissure,  intraparietal,  533 
of  anus,  665 
of  Bichat,  530 
of  Rolando,  531 

Chiene's  method  of  locating,  531 
Horsley's  method  of  locating,  532 
of  Sylvius,  532 
Fistula,  10 1,  108 

in  ano,  662 
Fixed  dressings,  692 
Flat-foot,  523 
Floating  kidney,  701 
Foot,  amputation  of,  771 
Forearm,  amputation  of,  769 
Foreign  bodies  in  air-passages,  585 
in  alimentary  canal,  611 
in  lar)'nx,  586 
in  nose,  583 
in  oesophagus,  605 
in  phar}-nx,  586 
in  rectum,  662 
in  trachea,  587 
in  urethra,  740 
Fox's  apparatus,  350 
Fracture-sprains,  424 
Fractures,  306 
Barton's,  368 
by  contre-coup,  310 
causes  of,  311 
Colles's,  368 
comminuted,  310 
complete,  307 
complicated,  307 
compound,  307 


796 


INDEX. 


Fractures,  compound,  treatment  of,  326 
crepitus  in,  3 1 7 
deformity  in,  314 
diagnosis  of,  318 
direct,  310 

displacement  in,  varieties  of,  315 
extravasation  of  blood  in,  316 
"green-stick,"  308 
impacted,  310 
incomplete,  307 
indirect,  310 
in  elbow-joint,  361 
intra-uterine,  311 
loss  of  function  in,  316 
multiple,  310 
near  elbow-joint,  361 
non-union  of,  322 
cedema  in,  325 
of  acetabulum,  346 
of  bones  of  foot,  393 
of  carpus,  371 
of  clavicle,  348 

acromial  end  of,  35 1 

shaft  of,  348 

sternal  end  of,  352 
of  coccyx,  347 
of  costal  cartilages,  340 
of  false  pelvis,  343 
of  femur,  372 

above  condyles,  383 

extracapsular,  372-379 

great  trochanter  of,  380 

intracapsular,  372 

longitudinal  up  from  knee,  385 

separating  either  condyle,  384 

shaft  of,  381 

upper  extremity  of,  372 
of  fibula,  390 

lower  third  of,  390 

upper  two-thirds  of,  390 
of  forearm,  both  bones,  370 
of  humerus,  354 

anatomical  neck  of,  354 

at  base  of  the  condyles,  361 

epicondyle  of,  360 

external  condyle  of,  360 

head  of,  357 

internal  condyle  of,  361 

lower  extremity  of,  360 

shaft  of,  359 

surgical  neck  of,  354-35^ 

T-fracture,  361 

upper  extremity,  354 


Fractures  of  hyoid  bone,  335 
of  inferior  maxillary  bone,  333 
of  laryngeal  cartilages,  336 
of  leg,  388,  392 
of  malar  bone,  333 
of  metacarpal  bones,  371 
of  metatarsal  bones,  395 
of  nasal  bones,  328 
of  OS  calcis,  393 
of  patella,  385 

transverse,  386 
of  pelvis,  343 
of  penis,  754 
of  phalanges,  372 

of  toes,  395 
of  radius,  365 

above  insertion  of  pronator  radii 
teres  muscle,  366 

below  insertion  of  pronator  radii 
teres  muscle,  367 

head  of,  365 

lower  extremity,  368 

neck  of,  366 

shaft  of,  366 
of  ribs,  337 
of  sacrum,  346 
of  scapula,  352 

acromion  process  of,  353 

coracoid  process  of,  354 

glenoid  cavity  of,  353 

neck  of,  353 
of  skull,  544 

compound,  544 

depressed,  544 

non-depressed,  544 

of  inner  table  of,  544 

of  outer  tai)le  of,  544 

punctured,  544 

simple,  544 

trephining  for,  562 

vault  of,  544 
of  spine,  580 
of  sternum,  341 

of  superior  maxillary  bone,  331 
of  tibia,  388 

inner  malleolus  of,  389 
of  ulna,  363 

coronoid  process  of,  363 

olecranon  process  of,  363 

styloid  process  of,  365 
of  zygomatic  arch,  333 
pain  in,  314 
pathological,  310 


INDEX. 


^ 


797 


Fractures,  Pott's,  391 

preternatural  mobility  in,  316 

repair  of,  320 

simple,  306 

spontaneous,  310 

stellate,  310 

strain-,  308 

symptoms  of,  314 

treatment  of,  322 

ununited,  310 

varieties  of,  306 

vicious  union  in,  328 

with  dislocation,  325 
Freezing,  death  by,  677 
Frost-bite,  677 
Fumigation  in  syphilis,  183 
Fungus  cerebri,  551 
Funicular  hernia,  653 

hydrocle,  760 
Furuncle,  679 

Gall-stones  in  obstructed  bowel,  614 
Ganglia,  512 
Gangrene,  109 

acute,  113 

amputation  for,  121 

chronic,  no 

classification  of,  109 

decubital,  120 

diabetic,  117 

dry,  109,  no 

forms  of,  109,  no 

from  ergotism,  1 17 

from  frost-bite,  118 

hospital,  115 

moist,  109-H3 

of  penis,  754 

Pott's,  no 

Raynaud's,  116 

senile,  in 

septic,  1 09- 1 14 

symmetrical,  1 16 

traumatic  spreading,  1 15 
Gangrenous  appendicitis,  623 
Gant's  operation,  475 
Gastro-enterostomy,  6 1 2,  636 
Gastrostomy,  635 
Gauze,  antiseptic,  preparation  of,  783 

aseptic,  preparation  of,  784 

iodoform,  preparation  of,  784 
Genito-urinary  organs,  diseases  of,  696 

injuries  of,"696 
Genu  valgum,  520 


Genu  valgum,  osteotomy  for,  471 

varum,  521 
Germicides,  chemical,  24 
Gibson's  bandage,  689 
Girdner's  induction-balance,  550 
Glanders,  163 
Gleet,  745 
Glio-sarcoma,  213 
Globus  hystericus,  604 
Glottis,  oedema  of,  584 
Goitre,  779 

cystic,  779 

exophthalmic,  780 

fibrous,  780 

pulsating,  780 
Gonococcus,  32 
Gonorrhoea,  743,  745 

bacillus  of,  32 

in  female,  749 
Gonorrhoeal  arthritis,  412 
Gout,  rheumatic,  416 
Gouty  urethritis,  742 
Grafts,  omental,  634 
"Green-stick"  fracture,  308 
Growths  in  female  bladder,  736 
Gummata  of  syphilis,  179 

scrofulous,   142 
Gunshot  wounds,  149 

of  abdominal  wall,  610 

of  arteries,  244 

of  head,  550 

primary  hemorrhage  of,  254 

H.EMATEMESIS,  257 

Hgematocele,  760 
Haematoma,  148 

of  dura  mater,  552 
Haematuria,  696 

vesical,  714 
Hsemoglobinuria,  697 
Haemoptysis,  258 
Hallux  valgus,  523 

varus,  523 
Halstead's  suture,  632 
"Hammer-toe,"  523 
Hare-hp,  597 
Head,  contusions  of,  538 

diseases  of,  530 

gunshot  wounds  of,  550 

injuries  of,  537 
HeaUng  by  first  intention,  73 

by  granulation,  75 

by  second  intention,  74 


798 


INDEX. 


Healing  by  third  intention,  75 
Heait,  diseases  and  injuries  of,  224 
Heberden's  nodosities,  417 
Heineke-Mikulicz  operation,  613 
Hemorrhage,  244 

arrest  of,  151 

capillary,  treatment  of,  253 

cerebral,  542 

consecutive,  258 

constitutional  symptoms  of,  244,  245 

extradural,  542 

extramedullary,  580 

following  amputation,  762 
lateral  lithotomy,  256 

from  bladder,  256 

from  cerebral  sinus,  252 

from  deep  palmar  arch,  249 

from  diploe,  251 

from  ear,  255 

from   incomplete    division  of  artery, 
250 

from  intercostal  artery,  251 

from  internal  mammary  artery,  251 

from  large  bowel,  257 

from  leech-bite,  255 

from  lung,  258 

from  palmar  arch,  249 

from  prostate  gland,  256,  698 

from  punctured  wounds,  251 

from  small  bowel,  257 

from  stomach,  257 

from  tooth-socket,  252 

from  urethra,  255 

from  vessels  in  bony  canal,  251 

in  abdominal  section,  253 

intercurrent,  258 

intermediate,  258 

intra-abdominal,  253 

intracranial,  542 

intramedullary,  580 

primary,  golden  rules  for   procedure 
in,  249 

reactionary,  258 

rectal,  255 

recurrent,  258 

renal,  257 

secondary,  258 

subcutaneous,  255 

subdural,  543 

umbilical,  255 

urethral,  698 

uterine,  257 
Hemorrhagic  fever,  245 


Hemorrhagic  infarction,  124 

sarcoma,  213 
Hemorrhoids,  654 

excision  of,  658 

operative  treatment  of,  657 
Hepatitis,  pain  in,  43 
Hereditary  syphilis,  188 

treatment  of,  190 
Hernia,  abdominal,  640 

acquired,  654 

anatomical  varieties  of,  653 

causes  of,  641 

cerebri,  551 

congenital,  653 

diaphragmatic,  654 

direct  inguinal,  653 

femoral,  654 

Bassini's  operation  for  radical  cure 

of,  646 
Cheyne's  operation  for  radical  cure 

of,  646 
Salzer's  operation  for  radical  cure 
of,  646 

funicular,  653 

incarcerated,  641,  647 

infantile,  653 

inflamed,  641,  647 

inguinal,  Bassini's  operation  for,  646 
Macewen's  operation  for,  643 

into  foramen  of  Winslow,  654 

irreducible,  641,  646 

Littre's,  649 

lumbar,  654 

obstructed,  647 

obturator,  654 

of  brain,  551 

of  muscles,  509 

perineal,  654 

pudendal,  654 

reducible,  641 

radical  treatment  of,  643 

sciatic,  654 

strangulated,  641,  648 

umbilical,  654 

radical  cure  for,  646 

ventral,  654 
Hernial  sac,  640 
Herniotomy,  651-653 
Hesselbach's  triangle,  653 
Hey's  amputation  of  foot,  773 

internal  derangement  of  knee,  464 

line  of  amputation  of  foot,  772 
Hip-joint,  disarticulation  at,  777 


INDEX. 


799 


Hip-joint,  excision  of,  491 

tuberculosis  of,  400 
Hippocratic  countenance,  615 
Hodgkin's  disease,  203,  685 
Hollow-foot,  523 
Horns,  cutaneous,  215 
Horsley's  cyrtometer,  533 
Housemaid's  knee,  514 
Hutchinson's  teeth,  190 
Hydatid  moles  of  pregnancy,  203 
Hydrargyrism,  184 
Hydrencephalocele,  536 
Hydrocele,  758-760 
Hydrocephalic  cry,  554 
Hydrocephalus,  537,  553 
Hydrogen,  rectal   insufflation   of,  608, 

616 
Hydronephrosis,  707 
Hydrophobia,  162 
HydroiThachitis,  566 
Hyphomycetes,  18 
Hypodermatic  injections  of  mercury  va 

syphilis,  183 
Hypospadias,  752 
Hysteria,  permanent  stigmata  of,  578 

traumatic,  577 
Hysterical  joint,  420 

paralysis,  578 

stricture  of  oesophagus,  604 

Ileus  (intestinal  obstruction),  613 

Iliac  abscess,  99 

Ilio-femoral  triangle  of  Bryant,  375 

Immunity,  29 

Incontinence  of  retention,  711 

Indirect  cell-division,  76 

Induction-balance  of  Girdner,  550 

Infarction,  124 

Infection,  mixed,  30 

secondary,  30 

septic,  125 

syphilitic,  mixed,  168 
Infective  sinus  thrombosis,  559,  566 
Inflammation,  33 

causes  of,  41 

changes  in  perivascular  tissues  in,  38 

circulatory  changes  in,  2>Z 

classification  of,  39 

constitutional  symptoms  of,  47 
treatment  of,  60 

derangement  of  absorbents  in,  47 
of  secretions  in,  47 

diapedesis  in,  37 


Inflammation,  discoloration  in,  45 
disordered  functions  in,  46 
effusion  of  lymph  in,  82 

of  serum  in,  81 
extension  of,  40 
exudation  of  fluids  in,  36 
impairment  of  special   functions   in, 

46 
local  symptoms  of,  42 

treatment  of,  48 
migration  of  blood-corpuscles  in,  37 
of  antrum  of  Highmore,  583 
of  arteries,  227 
of  bone,  295 
of  brain,  traumatic,  551 
of  nerves,  524 
of  urethra,  741 
of  veins,  225 

oscillation  of  circulation  in,  36 
pain  in,  42 

purulent  infiltration  in,  87 
repair  in,  73 
retardation    of    the    circulation    in, 

34 
stagnation    of    the     circulation    in, 

swelling  in,  46 
symptoms  of,  42 
terminations  of,  41 
treatment  of,  47 
vascular  changes  in,  33 
Inflammatory  stricture  of  urethra,  750 
Ingrown  toe-nail,  682 
Inguinal  colostomy,  639 
Inoculations,  protective  and  preventive, 

29 
Insects,  bites  and  stings  of,  157 
Instruments,  disinfection  of,  782 
Insufflation  of  air  in  rupture  of  bladder, 
716 
of  hydrogen  gas  in  rupture  of  blad- 
der, 716 
in  rupture  of  intestine,  608 
in  rupture  of  stomach,  607 
Intercostal  neuralgia,  504 
Interdental  splints,  335 
Internal  derangement  of  knee,  Hey's, 

464 
Interpolation  in  plastic  surgery,  694     ' 
Intestinal  anastomosis,  637 
with  rings  (Senn"s),  637 
without  rings  (Abbe's),  638 
implantation,  637 


8oo 


INDEX. 


Intestinal  obstruction,  613 
calculi  in,  614 

caused  by  fecal  accumulations,  615 
by  foreign  bodies,  617 
by  gall-stones,  617 
by  tumors  outside  of  the  bowel, 
615 
classification  of,  613 
complete,  613 
intussusception,  614 
partial,  613 

passage  of  a  tube  in,  619 
seat  of,  616 

strangulation  caused  by  volvulus, 
614 
by  bands,  614 
in  apertures,  614 
stricture  of,  614 
treatment  of,  619 
tuberculosis,  143 
Intestine,  resection  of,  636 

suture  of,  632 
Intoxication,  putrid,  125 

septic,  125 
Intracranial  hemorrhage,  542 
Intubation  of  larynx,  585,  592 
Intussusception,  614,  616 
Involucrum,  302 
Iodoform  gauze,  784 
Iritis,  rheumatic,  177 

syphilitic,  177 
Ischio-rectal  abscess,  662 
Isthmus  of  thyroid  gland,  position  of, 
590 

Jacket,  plaster  of  Paris,  and  jury-mast, 

575 
Jacob's  ulcer,  107,  218 
Jarvis's  adjuster,  435 
Jobert's  suture,  632-634 
Johnson's  method  of  preparing  catgut, 

783 
Joint,  Brodie's  (hysterical),  420 

Charcot's,  419 

shoulder-,  dislocation  of,  441 
Joints,  aspiration  of,  480 

diseases  and  injuries  of,  295 

excision  of,  481 

loose  bodies  in,  428 

neuralgia  of,  421 

strumous,  398 

tuberculosis  of,  144 
Jones's  nasal  splint,  331 


Karyokinesis,  76 

Keen's  method  of  operation  for  Du- 

puytren's  contraction,  520 
Keloid  growths,  198 
Kidney,  abscess  of,  705 

dislocated,  701 

floating,  701 

laceration  of,  702 

movable,  701 

operation  on,  709 

perforating  wound  of,  703 

rupture  of,  702 

surgical,  708 
Knee,  housemaid's,  514 

operations  upon,  482 
Knee-joint,  arthrectomy  of,  482 

disease,  407 

excision  of,  493 
Knock-knee,  520 

osteotomy  for,  471 
Kocher's  method  of  excising  tongue, 
602 
of  gastro-enterostomy,  636 
of  reducing  shoulder-joint  disloca- 
tions, 444 
Koch's  circuit,  25 

tuberculin,  146 
Kraske's  operation,  662 
Kyphosis,  568,  572 

Laminectomy,  582 
Laparotomy,  629 

exploratory,  705 

in  intestinal  obstruction,  620 
Lardaceous  degeneration,  404 
Large  intestine,  identification  of,  608 
Laryngotomy,  quick,  591 
Laryngo-tracheotomy,  592 
Larynx,  anatomy  of,  589 

diseases  and  injuries  of,  584,  585 

intubation  of,  592 
Law  of  Colles,  188 

of  Miiller,  192 

of  Virchow,  192 
"  Lawn-tennis  arm,"  508 
Leiomyomata,  204 
Leiter's  coil,  396 

tubes,  425 
Lembert's  suture,  632,  635,  638 
Leptomeningitis,  551,  554,  556 
Leucomaines,  27 
Ligation  in  tabatidre,  269 

in  triangle  of  election,  282 


INDEX. 


8oi 


Ligation  in  triangle  of  necessity,  282 

of  arteries  in  continuity,  265 

of  axillar}'  artery,  274 

of  brachial  artery,  272 

of  carotid  arterj',  common,  280 
external,  283 
internal,  284 

of  dorsalis  pedis  artery,  285 

of  femoral  artery,  290 

of  iliac  arteries,  293 

of  lingual  arteiy,  285 

of  popliteal  artery,  290 

of  radial  arter)',  268 

of  subclavian  artery,  277 

of  tibial  artery,  anterior,  287 
posterior,  289 

of  ulnar  artery,  271 
Line  of  Nelaton  in  intracapsular  fracture 

of  femur,  375 
Lines  of  amputation  of  foot,  772,  773 
Lipomata,  196 
Liquor  Cotunnii,  547 
Lisfranc's  airiputation  of  foot,  771 
Lister's  cyanide  gauze,  784 
Liston's  modified  circular   amputation, 

765 
Litholapaxy  730 

in  male  children,  733 
Lithotomy,  726,  728,  735 
Lithotrity,  rapid,  730 
Uttr^'s  hernia,  649 
Local  anaesthetics,  666 

shock,  577 

venereal  sore,  752 
Lockjaw,  133 
Lordosis,  403,  568,  572 
Loreta's  operation,  613 
Lumbago,  504 
Lumbar  abscess,  403 

hernia,  654 

nephrectomy,  710 
Lumpy -jaw,  19 

Lungs,  diseases  and  injuries  of,  593 
Lupus,  142 

in  tertiary  syphilis,  180 
Luxations.     See  Dislocations. 
Lymph,  %i 
Lymphadenitis,  683 
Lymphangeiomata,  209 

cavernous,  210 
Lymphangiectasis,  684 
Lymphangioma,  6S4 
Lymphangitis,  683 

61 


Lymphatic  glands,  tuberculosis  of,  144 

warts,  684 
Lymphatics,  diseases  and  injuries  of,  683 

varicose,  684 
Lymphoma,  malignant,  685 
Lymphomata,  203 
Lymphorrhoea,  684 
Lympho-sarcoma,  212 
Lyssa,  162 

Macewen's    operation   for    congenital 
hernia,  644 
for  inguinal  hernia,  643 
for  knock-knee,  471 

supra-meatal  triangle,  534 
Macroglossia,  210 
Macula  eruption  of  syphilis,  173 
Madura-foot,  19 

Maisonneuve's  urethrotome,  752 
MaHgnant  oedema,  157 

tumors,  194 
Malingering,  578 

Marine  sponges,  preparation  of,  782 
Mason's  pins,  330 
Mastoid  disease,  557 

suppuration,  operation  for,  565 
Maxillary  antrum,  abscess  of,  584 
Maydl's  operation,  639 
McBurney's  point,  621,  624,  626 
McInt}Te  splint,  383 
Meatotomy,  751 
Meatus,  stricture  of,  751 
Meckel's  diverticulum,  614 
Meniere's  disease,  176 
Meningitis,  557 

traumatic,  55 1 

tuberculous,  553 
Meningocele,  536,  566 
Meningo-myelitis,  578 
Meningo-myelocele,  566 
Mercurial  inunctions  in  syphilis,  182 
Metacarpal  bones,  excision  of,  490 
Metastatic  abscess,  128 
Methods     of    distinguishing     between 

large  and  small  bowel,  609 
Microbes,  17 

antagonistic,  30 

of  suppuration,  31 

placental  transmission  of,  30 
Microcephalus,  535 
Micro-organisms,  17 
Microphyta,  18 
Micfozoaria,  18 


802 


INDEX. 


Micturition,  frequency  of,  699 
Miliary  aneurysm,  231 
Miner's  elbow,  514 
Mixed  infection,  30 
of  syphilis,  168 

tumors,  213 
Moles,  hydatid,  of  pregnancy,  203 
Mollities  ossium,  305 
Molluscum  fibrosum,  198,  207 
Monoplegia,  traumatic  hysterical,  578 
Monteggia's  dislocation,  462 
Moore's  dressings,  351 
Morbid  growths,  191 
Morbus  coxarius,  400 
Morphoea,  199 
Mortification,  109 
Morton's  fluid,  536,  567 
Mothers'  marks,  208 
Motor  areas,  533,  534 
Moulds,  18 

Mouth,  diseases  of,  597 
Mucous  patches  of  syphilis,  175 
Multilocular  cystic  tumors,  201 
Murphy's  button,  639 
Muscles,  atrophy  of,  505 

contractions  of,  509 

contusions  of,  507 

degeneration  of,  506 

diseases  and  injuries  of,  503 

hernia  of,  509 

hypertrophy  of,  505 

rupture  of,  508 

strains  of,  508 

tumors  of,  506 

wounds  of,  507 
Muscular  rheumatism  (myalgia),  503 
Myoma,  205 
Myomata,  204 

uterine  intramural,  205 
Myositis,  505 

ossificans,  506 
Myxomata,  202 
Myxo-sarcomata,  203 

NEVOID  lipoma,  209 
Nsevo  lipoma,  197 
Nsevus,  227 
Nails,  diseases  of,  678 
Natiform  skull,  189 
Neck,  triangles  of,  278 
Necrosis,  301 

coagulation,  128 
Needle,  calyx-eyed,  632,  638 


Neisser's  bacillus,  32 
Nelaton's  line,  374 
Neoplasms,  191 
Nephrectomy,  abdominal,  710 

lumbar,  710 
Nephritic  colic,  705 
Nephrolithotomy,  709 
Nephrorrhaphy,  71 1 
Nephrotomy,  709 
Nerve,  infraorbital,  neurectomy  of,  529 

pressure  upon,  526 

sciatic,  stretching  of,  529 

supraorbital,  neurectomy  of,  530 
Nerve-division,  trophic  changes  in,  526 
Nerve-suture,  527 
Nerves,  contusion  of,  527 

degeneration  of,  525 

diseases  and  injuries  of,  524,  525 

inflammation  of,  524 

operations  on,  527 

punctured  wounds  of,  527 

regeneration  of,  525 

section  of,  525 
Nervous  fever,  79 
Neuralgia,  525 

intercostal,  504 

of  joints,  421 

of  stumps,  treatment  of,  525 
Neurasthenia,  traumatic,  576 
Neurectasy,  528 
Neuritis,  524 

multiple,  524 
Neuroma,  207 
Neuromata,  207 

traumatic,  208 
Neuropathic  arthritis,  419 
Neurorrhaphy,  527 
Neurotomy,  528 
Nitrous  oxide,  666 
Nodosities,  Heberden's,  417 
Noma,  118 
Normal    salt-solution   in   skin-grafting, 

694 
Nose,  foreign  bodies  in,  583 

injuries  of,  583 

Obstruction,  intestinal,  613-615 

Obturator  hernia,  654 

Odontomata,  201 

O'Dwyer's   operation  of  intubation  of 

larynx,  592 
CEdema,  maUgnant,  157 
of  glottis,  584 


INDEX. 


803 


CEdema  of  lan'nx,  584 
CEsophageal  bougie,  604 
CEsophagostomy,  605 
CEsophagus,  diseases  of,  597 

excision  of,  605 

foreign  bodies  in,  605 

stricture  of,  603,  604 
Ogston's  operation,  473 
Omental  graft,  634 
Onychia,  682 

malignant,  682 
Operations  for  hare-lip,  598 

for  mastoid  suppuration,  565 

for  stone  in  women,  734 

for  varix  of  leg,  260 

Maydl's,  639 

on  abdomen,  629 

on  bladder,  726 

on  bones,  470 

on  brain,  562 

on  kidney,  709 

on  nerves,  527 

on  skull,  562 

on  spine,  582 

on  vascular  system,  260 

preparation  for,  781 

technique  of,  564 
Opium-poisoning,  541 
Optic  neuritis  in  fracture  of  base   of 

skull,  548 
Orchitis,  757 

Os  calcis,  excision  of,  394 
Ossificans,  myositis,  506 
Osteitis,  295 

strumous,  296 
Osteo-arthritis,  416 
Osteoclasis,  521 
Osteo-malacia,  305 
Osteomata,  200 
Osteo-myelitis,  acute  diffuse,  303 

chronic,  305 
Osteoperiostitis,  296 

diffuse,  297 
Osteoplastic  periostitis,  298 

resection  in  ankle-joint  disease,  409 
Osteoscopic  pains  of  syphilis,  177 
Osteotome,  471 
Osteotomy,  470,  515 

cuneiform,  471 

for  bent  libia,  473 

for  faulty  ankylosis  of  hip-joint,  473 
of  knee-joint,  475 

for  genu  valgum,  471 


Osteotomy  for  hallux  valgus,  476 
for  talipes  equino-varus,  476 
for  talipes  equinus,  477 
for  ununited  fracture,  477 
for  vicious  union  of  fracture,  476 
linear,  470 
longitudinal,  297 
of  shaft  of  femur  below  trochanters, 

475 
through  neck  of  femur,  473 
Overflow  of  retention,  711 

Pachymeningitis,  551,  552 
Pacqueliii's  cautery,  727 
Palate,  cleft,  597 
Palmar  arch,  hemorrhage  of,  249 

psoriasis  in  syphilis,  178 
Pancreatitis,  acute  hemorrhagic,  618 
Papillomata,  215 
Papular  syphilides,  174 
Paracentesis  auriculi,  260 

pericardii,  260 

thoracis,  594 
Paralysis,  hysterical,  578 

in  syphilis,  178-180 
Paraphimosis,  748 
Paraplegia,  idea  of,  577 
Parke's  solution,  591 
Paronychia,  512 
Penis,  amputation  of,  755 

cancer  of,  754 

diseases  and  injuries  of,  736 

fracture  of,  754 

gangrene  of,  754 
Perforating  ulcer  of  foot,  107 
Pericardium,  224 
Perineal  bruises,  736 

cystotomy,  lateral,  735 
median,  735 

hernia,  654 

section^  Cock's  method  of,  740 
Perinephric  abscess,  706 
Perinephritis,  706 
Periostitis,  chronic,  298 

in  syphilis,  177-179 
Peritoneum,  toilet  of, 

tuberculosis  of,  144 
Peritonitis,  626 

fibrino-plastic,  627 

plastic,  626 

primax)*,  626 

saline  cathartics  in  treatment  of,  61 1, 
628 


8o4 


INDEX. 


Peritonitis,  septic,  626 

suppurative,  627 

tubercular,  629 
Pernio,  677 
Pes  cavus,  523 

planus,  523 
Petit' s  tourniquet,  762 
Phagedsena,  119 
Phagocytes,  28 
Phagocytosis,  28 
Phalanges,  excision  of,  490 
Phantom  tumor,  618 
Phimosis,  754 
Phlebitis,  225 
Phlebotomy,  262 
Piles,  654 

Pirogoff's  amputation  of  foot,  774 
Placental  transmission  of  microbes,  30 
Plaster  bandage,  removal  of,  692 
Plaster  of  Paris  in  compound  fracture, 

327 
Plaster-of-Paris  bandage,  693 
Plastic  surgery,  693 
Pleura,  diseases  and  injuries  of,  593 
Pleuritic  effusion,  593 
Pleurodynia,  504 
Pneumatic  aspirator,  480 
Poison-ash,  678 
Poison-ivy,  678 
Poison-oak,  678 
Poisoned  wounds,  149 
Poly  dactyl  ism,  520 
Polyps,  203 

fibrous,  198 

fleshy,  205 

gelatinous,  203 

nasal,  203 
"  Port- wine  stains  "  of  skin,  209 
Pott's  disease,  573 

fracture,  391,  466 
Preventive  inoculations,  29 

trephining,  546 
Primary  amputation,  761 

angesthesia,  673 

peritonitis,  626 
Probang,  horse-hair,  604,  605 
Proctotomy,  661 
Prostate  gland,  diseases  and  injuries  of, 

736 

hypertrophy  of,  755 
Prostatic  abscess,  748 
Prostatitis,  748 
Protective  inoculations,  29 


Pruritus  of  anus,  665 
Psammomata,  215 
Psoas  abscess,  403 
Psorospermosis ,   1 94 
Psorosperms,  194 
Psychical  traumatism,  577 
Ptomaines,  27 
Ptyalism,  acute,  184 
Pudendal  hernia,  654 
Pulsating  goitre,  780 
Pus,  84,  85 

microbes,  31 
Pustular  syphilides,  174 
Putrid  intoxication,  125 
Pyaemia,  125-127 
Pyelitis,  706 
Pyelonephritis,  706 
Pylorectomy,  612,  634 
Pyloroplasty,  613 
Pylorus,  excision  of,  634 
Pyogenic  cocci,  31 
Pyonephrosis,  708 

Rabies,  162 

Railway  spine,  575-577 

Ranula,  601 

Ray  fungus,  19,  33,  164 

Reaction  of  degeneration,  524 

Reactionary  hemorrhage,  258 

Rectal   insufflation  of  hydrogen,  608, 

616 
Rectum,  cancer  of,  661 

cleansing  of,  785 

diseases  and  injuries  of,  654 

excision  of,  661 

foreign  bodies  in,  662 

prolapse  of,  658 

stricture  of,  660 

ulcer  of,  659 

wounds  of,  662 
Recurrent  hemorrhage,  258 
Reduction  of  hernia  en  bloc,  650 

en  masse,  650 
Reef-knot,  268 
Renal  calculus,  703 
Repair,  73 

Reptiles,  bites  of,  157 
Resection  of  bones.     See  Excision. 

of  intestine,  636 

of  joints.     See  Excision. 
Residual  abscess,  144 
Respiratory  organs,  surgery  of,  583 
Retained  testicle,  757 


INDEX. 


805 


Retention  of  urine,  711,  748 

incontinence  of,  7 1 1 
Retinitis,  diffused,  of  syphilis,  177 
Retrenchment  in  plastic  surgery,  694 
Reverdin's  method  of  skin-grafting,  694 
Rhabdomyomata,  205 
Rheumatic  arthritis,  414 

gout,  416 

iritis,  177 

torticollis,  504 
Rheumatism,  acute,  414 

chronic,  415 

gonorrhoeal,  412 

muscular,  503 
Rheumatoid  arthritis,  416 
Rhus-poisoning,  678 
Rib,  resection  of,  595 
Ribble's  bandage,  688 
Rickets,  147 
Rider's  leg,  508 
Rodent  ulcer,  218 
Rolando's  fissure,  531 
Roseola  of  syphilis,  173 
Rules  of  inheritance  of  syphihs,  188 
"  Run  around,"  682 
Rupia,  178,  I  So 
Rupture,  640 

Sacro-iliac  joint,  disease  of,  403 

"Saddle-back,"  572 

Salivation,  184 

Salzer's   operation  for   femoral  hernia, 

646 
Sapreemia,  125 
Sarcocele  in  syphilis,  177 
Sarcoma,  alveolar,  212 

black,  212 

erj'sipelas  in  treatment  of,  214 

giant-celled,  212 

glio-,  213 

hemorrhagic,  213 

lympho-,  212 

melanotic,  212 

mixed-celled,  212 

myeloid,  212 

plexiform,  213 
Sarcomata,  210 

round-celled,  212 

spindle-celled,  212 
Sayre's  knee-joint  splint,  408 

plaster-of- Paris  jacket,  574,  575 
Scalds,  675 

of  glottis,  676 


Scalp,  abscess  of,  534 

cirsoid  aneur^'sm  of,  534 

cysts  of,  534 

diseases  of,  534 

local  cutaneous  hypertrophies  of,  534 

lupus  of,  534 

moles  of,  534 

naevi  of,  534 

tumors  of,  534 

warts  of,  534 

wounds  of,  537 
Schizomycetes,  18 
Scirrhus,  219 
Scoliosis,  568 
Scrofula,  137,  141 
Scrofulodermata,  142 
Scrofulous  gummata,  142 
Scybala  as  a  cause  of  appendicitis,  621 
Secondary  amputation,  761 
Sedillot's  amputation  of  leg,  774 
Segmentation  of  cells,  21 
Senn's  apparatus  for  intracapsular  frac- 
ture of  femur,  377 

bone  plates,  638 

decalcified  bone-chips,  785 

method  for  gastro-enterostomy,  636 
Septic  arthritis,  41 1 

infection,  125 

intoxication,  125 

peritonitis,  626 

wounds,  149 
Septicemia,  125 
Sequestrum,  301 
Serum,  effusion  of,  81 
Shock,  150 

local,  577 

of  anaesthesia,  671 
Shoulder-joint  disease,  409 

excision  of,  483 
Signorini's  horseshoe  tourniquet,  764 
Silicate-of-soda  dressings,  693 
Silk  sutures,  preparation  of,  783 
Silkworm  gut,  preparation  of,  783 
Sinus,  T08 

rupture  of,  544 

thrombosis,  557 
infective,  559 
Skin,  diseases  of,  678 
syphilitic,  172 

tuberculosis  of,  142 
Skin-grafting,  694 

Reverdin's  method,  694 

Thiersch's  method,  695 


8o6 


INDEX. 


Skull,  fracture  of,  544. 

Sloughing,  119 

Small  intestine,  identification  of,  608 

Smith's  (Nathan  R.)  splint,  383 

Snakes,  bites  of,  159 

Snuffles  in  hereditary  syphilis,  189 

Spermatic  cord,  diseases  and  injuries  of, 

736 

Sphacelus,  109 
Spina  bifida,  566 
Spinal  caries,  403,  573 

cord,  compression  of,  580 
concussion  of,  579 
contusion  of,  579 
wounds  of,  579 

curvature,  568 

ligament,  injuries  of,  575 

muscles,  injuries  of,  575 
Spine,  angular  curvature  of,  568,  573 

anterior  curvature  of,  568,  572 

antero-posterior  curvature  of,  572 

cervical  curve  of,  568 

congenital  deformities  of,  566    . 

dislocation  of,  580 

dorsal  curve  of,  568 

fracture  of,  424,  580 

fracture-dislocation  of,  581 

lateral  curvature  of,  569 

lumbar  curve  of,  568 

operations  upon,  582 

pelvic  curve  of,  569 

posterior  curvature  of,  568 

primary  curve  of,  569 

railway,  575,  577 

surgery  of,  566 

tumors  of,  567 
Spirillum,  20 
Spores,  21 
Sprains,  423 
St.  Anthony's  fire,  129 
Staphylococci,  20 
Staphylococcus  pyogenes  albus,  31 
aureus,  21,  31 
citreus,  31 
Staphylorrhaphy,  600 
Stay-knot,  268 
Stercoraceous  vomiting,  615 
Stercoral  appendicitis,  622 
Sthenic  fever,  78 
Stings  of  insects,  157 
Stomach,  cancer  of,  61 1 

cicatricial  stenosis  of  orifices  of,  612 
rupture  of,  607 


Stone  in  bladder,  717 
Strain,  508 
Strain-fracture,  308 
Strangulation,  intestinal,  614 
Streptococci,  20 
Streptococcus  erysipelatis,  32 

pyogenes,  31,  32 
Stricture  of  intestine,  614 

of  meatus,  751 

of  oesophagus,  603 

of  rectum,  660 

of  urethra,  750 
Stromeyer's  anterior  angular  splint,  410 
Strumous  caries,  296,  299 

joint,  398 

osteitis,  296 
Subcutaneous  painful  tubercle,  198, 208 
Suggillation,  148 
Sulcus,  precentral,  533 
Suppuration,  84,  87 

of  mastoid,  operation  for,  565 

organisms  of,  31,  88 

without  organisms,  32,  84 
Surgical  cleanliness,  antiseptic,  780 
aseptic,  780 

dressings,  preparation  of,  783 

fevers,  77 

kidney,  708 
Suture,  Cushing's,  632,  638 

Czerny-Lembert,  632 

Dupuytren's,  632 

Halstead's,  632 

Jobert's,  632 

Lembert's,  632 

of  intestine,  632 

Wolfler's,  634 
Sylvius,  fissure  of,  532 
Syme's  amputation  at  ankle-joint,  773 

of  leg,  776 
Syndactylism,  520 

Synovial   membrane,  pulpy  degenera- 
tion of,  144 
Synovitis,  395-399 
Syphilides,  172-175 
Syphilis,  165 

acquired,  166 

affections  of  bones  in,  176 
of  ear  in,  176 
of  eye  in,  177 
of  hair  in,  176 
of  joints  in,  176 
of  mucous  membrane  in,  1 75 
of  nails  in,  176 


INDEX. 


807 


Syphilis,  affections  of  testes  in,  177 

alopecia  in,  176 

arteritis  in,  178 

bubo  of,  171 

catarrhal  inflammations  in,  175 

chancre  of,  168 

choroiditis,  disseminated,  in,  177 

condylomata  of,  1 75 

continuous  treatment  of,  182 

dactylitis  in,  190 

deafness  of,  190 

erythema  of,  173 

fumigation  in,  183 

general,  172 

gummata  in,  179 

hereditan^  166,  188 

hypodermatic   injections  of  mercury 
for,  183 

infection  in  utero,  188 

inflammation  of  tongue  in,  180 

initial  lesion  of,  168 

intermediate  period  of,  177 

intermittent  treatment  of,  181 

iritis  in,  177 

macular  eruption  of,  173 

mercurial  inunctions  in,  182 

mucous  patches  of,  175 

natiform  skull  in,  189 

obliterative  endarteritis  in,  178 

of  mucous  membranes,  175 

osteoscopic  pain  in,  177 

palmar  psoriasis  in,  178 

paralysis  in,  178-lSo 

periods  of,  167 

periostitis  of,  177-179 

primary,   1 67 

reminders  of,  177 

retinitis,  diffused,  in,  177 

roseola  of,  173 

rules  of  inheritance  of,  188 

secondar)',  172 

snuffles  in  hereditar}',  189 

tertiary,  178 

tonsils  in,  175 

transmission  of,  166 

treatment  of  primary  stage  of,  180 
of  secondary  stage  of,  181 
of  tertiary  stage  of,  187 

ulcers  of,  179 

warts  of,  175 
Syphilitic  sarcocele,  177 
Syphilodermata,  172 
Syringo-myelocele,  566 


Tabetic  arthropathy,  419 
Talipes,  521 

calcaneus,  521 

equino-varus,  osteotomy  for,  476 

equinus,  521 

osteotomy  for,  477 

valgus,  521 

varus,  521 
Taxis,  649 
Teleangiectasis,  209 
Temporo-sphenoidal   lobe,    abscess  in, 

559 
Tendo  Achillis,  tenotomy  of,  515 
Tendon-lengthening,  516 
Tendon-suture,  516 
Tendons,  diseases  and  injuries  of,  503 

dislocation  of,  509 

operations  upon,  515 

rupture  of,  510 

wounds  of,  510 
Teno-synovitis,  510 
Tenotome,  515 
Tenotomy,  515 

in  torticollis,  519 

of  tendo  Achillis,  515 
Testicles,  diseases  and  injuries  of,  736 

excision  of,  758 

retained,  757 
Tetanus,  133 

antitoxine  of,  137 

bacillus  of,  32 
Thecitis,  510 

Theory  of  Cohnheim,  193 
Thiersch's  method  of  skin-grafting,  695 
Thompson's  diagnostic  questions,  700 
Thoracoplasty,  596 
Thoracotomy,  595 
Thrombosis,  122 
Thyroidectomy,  780 
Toe-nail,  ingrown,  682 
Toes,  amputation  of,  771 
Toilet  of  peritoneum,  631 
Tongue,  diseases  of,  597 

excision  of,  602 
Tongue-tie,  601 

Topography,  cranio-cerebral,  530,  534 
Torcular  Herophili,  560 
Torticollis,  504,  518 
Toxalbumins,  26 
Toxines,  26 
Trachea,  anatomy  of,  589 

diseases  and  injuries  of,  584 
Tracheotomy,  588 


8o8 


INDEX. 


Tracheotomy,  high,  590 
Transfusion,  arterial,  265 

of  blood,  263 
Traumatic  fever,  80 

hysteria,  577 

neurasthenia,  576,  577 
Traumatism,  psychical,  577 
Trendelenburg's  canula,  337 

position,  589,  630,  729 
Trephining,  562 

in  fracture  of  skull,  545 

preventive,  546 
Treves's  operation  for  vertebral  caries, 

582 
Triangle  of  election,  ligation  in,  282 

of  Hesselbach,  653 

of  necessity,  ligation  in,  282 

of  neck,  278 
Trichinosis,  505 
Trophic   changes    from    nerve-division, 

526 
Truss,  measurements  for  a,  642 
Tubercle,  138 

painful  subcutaneous,  198,  208 
Tubercular  adenitis,  144 

arthritis,  398 

orchitis,  757 

peritonitis,  144,' 629 

syphilides,  175 

ulceration  of  rectum,  659 
Tuberculin,  Koch's,  146 
Tuberculosis,  137 

diagnosis  of,  145 

of  alimentary  canal,  143 

of  brain,  144 

of  hip-joint,  400 

of  intestines,  143 

of  lymphatic  glands,  144 

of  peritoneum,  144,  629 

of  skin,  142 

of  special  joints,  144,  400 

of  subcutaneous  connective  tissue,  143 

prognosis  of,  145 
Tuberculous  abscess,  90,  97,  142 

disease  of  joints,  144,  400 

meningitis,  553 

urethritis,  743 
Tubes,  Leiter's,  425 
Tubular  lymphangitis,  683 
Tumors,  191 

benign,  194 

causes  of,  193 

classes  of,  192 


Tumors,  classification  of,  195 
cystic  multilocular,  201 
fatty,  196 

hereditation  in,  193 
heterologous,  192 
innocent  connective-tissue,  196 

epithelial,  215 
intracranial,  560 
malignant,  194 

connective-tissue,  210 

epithelial,  217 
mixed,  213 
of  bladder,  725 
of  brain,  557,  560 
of  muscles,  506 
of  spine,  567 
parasitic  influence  in,  193 
phantom,  618 
psorosperm,  194 
Tunica  vaginalis,  diseases  and  injuries 
of,  736 

Ulcers,  ioi 

acute,  103 

chronic,  of  leg,  104 

classification  of,  102 

forms  of,  107 

Jacob's,  107,  218,  219 

of  the  rectum,  659 

proud  flesh  in,  106 

rodent,  107,  218 

superfluous  granulations  in,  106 

symmetrical,  of  tonsil,  175 

syphilitic,  179 
Ulceration,  loi 
Uraemia,  541 
Uranoplasty,  600 
Ureter,  bleeding  from,  697 
Ureterolithotomy,  705 
Urethra,  diseases  and  injuries  of,  736 

foreign  bodies  in,  740 

inflammation  of,  741 

rupture  of,  737 

stricture  of,  750 
Urethral  discharges,  chronic,  745 

fever,  751 

hemorrhage,  698 

rupture,  737 
Urethritis,  741 
Urethrotomy,  751,  752 
Urine,  extravasation  of,  739 

retention  of,  71 1,  748 
Uterus,  fibroid  tumors  of,  205 


INDEX. 


809 


Vagina,  cleansing  of,  785 
Vaginal  hsematocele,  760 
Varicocele,  760 

open  operation  for,  261 

subcutaneous  ligature  for,  261 
Varicose  veins,  225,  253 
Varix,  225 

of  leg,  operations  for,  260 
Vascular  system,  operations  on,  260 
Veins,  inflammation  of,  225-227 

varicose,  225 

wounds  of,  244 
Velpeau's  bandage,  350,  690 
Venereal  catarrh,  743 

sore,  local,  752 

warts,  216 
Venesection,  262 
Venous  piles,  656 

Vermiform  appendix  of  csecum,  620 
Verruca  necrogenica  of  Wilks,  142 
Vesical  hasmaturia,  714 

hemorrhage,   including   hemorrhage 
from  prostate,  698 
Virchow's  law,  192 
Volkmann's  dorsal  splint  for  excision  of 

ankle,  496 
Volvulus,  614,  617 
Von  Graefe's  sign,  780 

Wart-horn,  215 
Warts,  215 

of  syphilis,  175 
Wasps,  stings  of,  157 
Water  on  brain,  553 
Waxy  degeneration,  404 
Webbed  fingers,  520 

Agnew's  operation  for,  520 
Diday's  operation  for,  520 
White  swelHng,  144,  398,  407 
White's  rule  of  syphilitic  stages,  197 
Whitehead's  operation  for  piles,  658 
Whitlow,  512 

Wire,  introduction  of,  in  aneurysm,  240 
Wiring  for  ununited  fracture,  477 
Witzel's  method  of  gastrostomy,  635 
Wolfler's  suture,  634 
Wound-fever,  primary,  80 

secondary,  81 
Wounds,  148 


Wounds,  articular,  422 

penetrating,  423 
aseptic,  149 
cleansing  of,  152 
closure  of,  152 

constitutional  treatment  of,  153 
contused,  149-153 
dissecting,  156 
drainage  of,  152 
dressing  of,  152 
gunshot,  149,  153,  244 

of  arteries,  244 
incised,  149,  153 
lacerated,  149,  153 

of  arteries,  243 
non-penetrating,  422 
of  abdominal  wall,  610 

contused,  243 

incised,  243 
of  brain,  549 
of  chest,  594 
of  head,  penetrating,  550 
of  larynx,  585 
of  muscles,  507 
of  nerves,  525 
of  scalp,  537 
of  spinal  cord,  579 
of  tendons,  510 
of  veins,  244 
open,  149 
poisoned,  149,  156 
punctured,  149,  154 

of  arteries,  244 
septic,  149,  156 
subcutaneous,  149 
treatment  of,  151 
Wrist-joint,  amputation  at,  768 
disease,  410 

excision  in,  41 1 
Wr}'-neck,  518 

Wyeth's  bloodless  amputation  at  hip- 
joint,  777 
pins  in  hip-  and  shoulder-joint  am- 
putations, 764,  777 

Yeasts,  18 

ZooGLCEA.  20 


PUBLISHED    BY 

W.  B.  SAUNDERS,  925  Walnut  Street,  Philadelphia,  Pa. 


PAGE 

♦American  Text-Book  of  Applied  Thera- 
peutics   3 

♦American  Text-Book  of  Diseases  of  Chil- 
dren     3 

♦American  Text-Book  of  Gynecology  .  4 
♦American  Text-Book  of  Nursing  ....  8 
♦American  Text-Book  of  Obstetrics  ...  8 
♦American  Text- Book  of  Physiology  ...  8 
♦.American  Text-Book  of  Practice  ....  2 
♦American  Text-Book  of  Surgery     .    .    .    .     i 

Ashton's  Obstetrics 23 

Ball's  Bacteriology 27 

Bastin's  Laboratory  Exercises  in  Botanj'  .  18 

Beck's  Surgical  Asepsis 12 

Brockway's  Physics 27 

Burr's  Nervous  Diseases      12 

Cerna's  Notes  on  the  Newer  Remedies  .  .  18 
Chapman's    Medical    Jurisprudence     and 

Toxicology 14 

Cohen  and  Eshner's  Diagnosis 26 

Cragin's  Gynaecology 24 

DaCost.a's  Manual  of  Surgery 13 

♦De  Schweinitz's  Diseases  of  the  Eye    .    .    5 

Dorland's  Obstetrics      13 

Frothingham's    Guide    to    Bacteriological 

Laboratory      14 

Garrigues'  Diseases  of  Women 10 

Gleason's  Diseases  of  the  Ear 28 

Griffin's  Materia  Medica  and  Therapeutics  12 

♦Gross's  Autobiography 7 

Hare's  Physiology 22 

Hampton's    Nursing :    its    Principles   and 

Practice 15 

Hyde's  Syphilis  and  Venereal  Diseases  .  .  12 
Jackson  and  Gleason's  Diseases  of  the  Eye, 

Nose,  and  Throat      25 

Jewett's  Outlines  of  Obstetrics 18 

♦Keating's     Pronouncing     Dictionary     of 

Medicine      7 

Keating's   How  to   E.xamine  for   Life  In- 
surance      20 


PAGE 

Keen's  Operation  Blanks 16 

Kyle's  Diseases  of  Nose  and  Throat  ...  12 

Laine's  Temperature  Charts 9 

Lockwood's  Practice  of  Medicine    ....  12 

Long's  Syllabus  of  Gj'necology 9 

Martin's  Surgery 22 

]\Iartin's  Minor  Surgery,   Bandaging,  and 

Venereal  Diseases 25 

Morris'  Materia  Medica  and  Therapeutics  23 

Morris'  Practice  of  IMedicine 24 

IMorton's  Nurses'   Dictionary 9 

Nancrede's  Anatomy  and  Manual  of  Dis- 
section   16 

Nancrede's  Anatomj' 22 

Norris'  Syllabus  of  Obstetrical  Lectures    .  17 

Powell's  Diseases  of  Children 26 

Raymond's  Physiology 13 

Saunders'  Pocket  Medical  Formulary  .  .  19 
Saunders'  Pocket  Medical  Lexicon  ....  19 
Saunders'  New  Aid  Series  of  Manuals  .  11,  12 
Saunders'  Series  of  Question  Compends   .  21 

Sayre's  Practice  of  Pharmacy 26 

Semple's  Pathologj'  and  Morbid. Anatomy  23 
Semple's  Legal  IMedicine,  Toxicology,  and 

Hygiene 25 

Senn's  Syllabus  of  Lectures  on  Surgery  .    .  17 
Shaw's  Nervous  Diseases  and  Insanity  .    .  27 
Stelwagon's  Diseases  of  the  Skin    ....  24 
Stevens'   Materia  Medica  and  Therapeu- 
tics      20 

Stevens'  Practice  of  Medicine 17 

Stewart   and    Lawrance's    Medical    Elec- 
tricity     28 

Thornton's  Dose-Book  and  Manual  of  Pre- 
scription-Writing     14 

♦Vierordt  and  Stuart's    Medical   Diagno- 
sis   6 

Warren's  Surgical  Pathology 10 

Wilson's  Orthopaedic  Surgery 15 

Wolffs  Chemistry 23 

WolflF's  Examination  of  Urine 26 


Mr.  Saunders,  in  presenting  to  the  profession  the  following  list  of  his  publications,  begs 
to  state  that  the  aim  has  been  to  make  them  worthy  of  the  confidence  of  medical  book-buyers 
by  the  high  standard  oi  authorship  and  by  the  excellence  oi  typography ,  paper ,  printing, 
and  biiuiing. 

The  works  indicated  thus  (♦)  are  sold  by  stJBSCRiPTiON  (not  by  booksellers) ,  usually 
through  travelling  solicitors,  but  they  can  be  obtained  direct  from  the  office  of  publication 
(charges  of  shipment  prepaid)  by  remitting  the  quotpd  prices.  Full  descriptive  cirulars  of 
such  works  will  be  sent  to  any  address  upon  application. 

All  the  other  books  advertised  in  this  catalogue  are  commonly  for  sale  by  booksellers  in 
all  parts  of  the  United  States  ;  but  any  book  will  be  sent  by  the  publisher  to  any  address 
(post-paid)  on  receipt  of  the  price  herein  given. 

[For  Announcement  of  Forthcoming  Publications  see  tiext page.) 


Bnuouucement  of  ffortbcomino  publications* 


AN  AMERICAN  TEXT-BOOK  OF  OBSTETRICS.  By  Amer- 
ican Teachers.     (See  page  8.) 

AN  AMERICAN  TEXT-BOOK  OF  PHYSIOLOGY.  By  Amer- 
ican Teachers.     (See  page  8.) 

AN  AMERICAN  TEXT-BOOK  OF  APPLIED  THERAPEU- 
TICS.    By  American  Teachers. 

AN  AMERICAN  TEXT-BOOK  OF  NURSING.  By  American 
Teachers. 

SURGICAL  PATHOLOGY  AND  THERAPEUTICS.  By  J.  Col- 
lins Warren,  M.  D.,  Professor  of  Surgery,  Harvard  Medical  School, 
etc.     (See  page   lo.) 

A  SYLLABUS  OF  GYNECOLOGY,  arranged  in  conformity  with 
The  American  Text-Book  of  Gynecology.  By  J.  W.  Long,  M.  D., 
Professor  of  Diseases  of  Women  and  Children,  Medical  College  of  Vir- 
ginia, etc.     (See  page  9.) 

TEMPERATURE  CHART.  Prepared  by  D.  T.  Laine,  M.  D.  (See 
page  9.) 

LABORATORY  EXERCISES  IN  BOTANY.  By  Edson  S.  Bas- 
tin,  M.  a.,  Professor  of  Materia  Medica  and  Botany  in  the  Philadelphia 
College  of  Pharmacy.     (See  page  18.) 

A  GUIDE  TO  THE  BACTERIOLOGICAL  LABORATORY.    By 

Langdon  Frothingham,  M.D      (See  page  14.) 

SAUNDERS'  NEW  AID  SERIES  OF  MANUALS. 

New  volumes  in  active  preparation.     See  pages  ji,  12. 


For  Sale  by  Subscrii>tion. 


AN  AMERICAN  TEXT-BOOK  OF  SURGERY.  Edited  by  Wil- 
liam \V.  Keen,  M.  D.,  LL.D.,  and  J.  William  White,  M.  D.,  Ph.D. 
Forming  one  handsome  royal-octavo  volume  of  over  1200  pages  (10x7 
inches),  with  nearly  500  wood-cuts  in  text,  and  37  colored  and  half-tone 
plates,  many  of  them  engraved  from  original  photographs  and  drawings 
furnished  by  the  authors.  Prices:  Cloth,  $7.00  net;  Sheep,  ^8.00  net; 
Half  Russia,  $9.00  net. 

The  want  of  a  text-book  which  could  be  used  by  the  practitioner  and  at  the 
same,  time  be  recommended  to  the  medical  student  has  been  deeply  felt,  espe- 
cially by  teachers  of  surgery;  hence,  when  it  was  suggested  to  a  number  of 
these  that  it  would  be  well  to  unite  in  preparing  a  text-book  of  this  description, 
great  unanimity  of  opinion  was  found  to  exist,  and  the  gentlemen  below  named 
gladly  consented  to  join  in  its  production.  While  there  is  no  distinctive  Amer- 
ican Surgery,  yet  America  has  contributed  very  largely  to  the  progress  of  modern 
surgery,  and  among  the  foremost  of  those  who  have  aided  in  developing  this  art 
and  science  will  be  found  the  authors  of  the  present  volume.  All  of  them  are 
teachers  of  surgery  in  leading  medical  schools  and  hospitals  in  the  United  States 
and  Canada. 

Especial  prominence  has  been  given  to  Surgical  Bacteriology,  a  feature  which 
is  believed  to  be  unique  in  a  surgical  text-book  in  the  English  language.  Asep- 
sis and  Antisepsis  have  received  particular  attention.  The  text  is  brought  well 
up  to  date  in  such  important  branches  as  cerebral,  spinal,  intestinal,  and  pelvic 
surgery,  the  most  important  and  newest  operations  in  these  departments  being 
described  and  illustrated. 

The  text  of  the  entire  book  has  been  submitted  to  all  the  authors  for  their 
mutual  criticism  and  revision — an  idea  in  book-making  that  is  entirely  new  and 
original.  The  book  as  a  whole,  therefore,  expresses  on  all  the  important  sur- 
gical topics  of  the  day  the  consensus  of  opinion  of  the  eminent  surgeons  who 
have  joined  in  its  preparation. 

One  of  the  most  attractive  features  of  the  book  is  its  illustrations.  Very 
many  of  them  are  original  and  faithful  reproductions  of  photographs  taken 
directly  from  patients  or  from  specimens,  and  the  modern  improvements  in  the 
art  of  engraving  have  enabled  the  publisher  to  produce  illustrations  which  it  is 
believed  are  superior  to  those  in  any  similar  work. 

COXTRIBITORS : 

Dr.  Charles  H.  Burnett,  Philadelphia.  Dr.  Nicholas  Senn,  ('hicago. 

Phineas  S.  Conner,  Cincinnati.  1  Francis  J.  Shepherd.  Montreal,  Canada. 

Frederic  S.  Dennis,  New  York.  Lewis  A.  Stimson,  New  York. 

William  \Y,  Keen,  Philadelphia.  William  Thom.son,  Philadelphia. 

Charles  B.  Nancrede,  Ann  Arbor,  Mich.  '  J.  Collins  Warren,  Boston. 

Roswell  Park,  Buffalo,  N.  Y.  1  J.  William  White,  Philadelphia. 

Lewis  S.  Pilcher,  New  York.  ' 

"  If  this  text-book  is  a  fair  reflex  of  the  present  position  of  American  surgery,  we  must 
admit  it  is  of  a  very  high  order  of  merit,  and  that  English  surgeons  will  have  to  look  very 
carefully  to  their  laurels  if  they  are  to  preserve  a  position  in  the  van  of  surgical  practice." — 

London  Lancet. 

"  The  soundness  of  the  teachings  contained  in  this  work  needs  no  stronger  guarantee  than 
is  afforded  by  the  names  of  its  authors." — Medical  News,  Philadelphia. 


IV.   B.   SAUNDERS' 


For  Sale  by  Svibscriptioii. 


AN  AMERICAN  TEXT-BOOK  ON  THE  THEORY  AND 
PRACTICE  OF  MEDICINE.  By  American  Teachers.  Edited 
by  William  Pepper,  M.  D.,  LL.D.,  Provost  and  Professor  of  the  Theory 
and  Practice  of  Medicine  and  of  Clinical  Medicine  in  the  University  of 
Pennsylvania.  Complete  in  two  handsome  royal-octavo  volumes  of  about 
looo  pages  each,  with  illustrations  to  elucidate  the  text  wherever  necessary. 
Price  per  Volume  :  Cloth,  ^5.00  net;  Sheep,  $6.00  net;  Half  Russia,  ^7.00 
net. 

VOLUME   I.   COJTTAINS: 

Hygiene. — Fevers  (Ephemeral,  Simple  Con-  I  mycosis.   Glanders,  and  Tetanus.  — Tubercu- 


tinued,  Typhus,  Typhoid,  Epidemic  Cerebro- 
spinal Meningitis,  and  Relapsing). — Scarla- 
tina, Measles,  Rotheln,  Variola,  Varioloid, 
Vaccinia, Varicella,  Mumps, Whooping-cough, 
Anthrax,  Hydrophobia,  Trichinosis,  Actino- 


losis,  Scrofula,  Syphilis.  Diphtheria,  Erysipe- 
las, Malaria,  Cholera,  and  Yellow  Fever. — 
Nervous,  Muscular,  and  Mental  Diseases  etc. 


VOI.UME   II.  CONTAINS: 

Urine  (Chemistry  and  Microscopy). — Kid-  '  — Peritoneum,  Liver, and  Pancreas. — Diathet- 
ney  and  Lungs. — Air-passages  (Larynx  and  ,  ic  Diseases  (Rheumatism,  Rheumatoid  Ar- 
Bronchi)  and  Pleura.  —  Pharynx,  QEsophagus,  I  thritis.  Gout,  Lithaemia,  and  Diabetes.) — 
Stomach  and  Intestines  (including  Intestinal  j  Blood  and  Spleen. — Inflammation,  Embolism, 
Parasites),  Heart,  Aorta,  Arteries  and  Veins.  \  Thrombosis,  Fever,  and  Bacteriology. 

The  articles  are  not  written  as  though  addressed  to  students  in  lectures,  but 
are  exhaustive  descriptions  of  diseases,  with  the  newest  facts  as  regards  Causa- 
tion, Symptomatology,  Diagnosis,  Prognosis,  and  Treatment,  including  a  large 
number  of  approved  formulae.  The  recent  advances  made  in  the  study 
of  the  bacterial  origin  of  various  diseases  are  fully  described,  as  well  as  the 
bearing  of  the  knowledge  so  gained  upon  prevention  and  cure.  The  subjects 
of  Bacteriology  as  a  whole  and  of  Immunity  nre  fully  considered  in  a  separate 
section. 

Methods  of  diagnosis  are  given  the  most  minute  and  careful  attention,  thus 
enabling  the  reader  to  learn  the  very  latest  methods  of  investigation  without 
consulting  works  specially  devoted  to  the  subject. 


CONTRIBITTORS : 


Dr.  J.  S.  Billings,  Philadelphia. 
Francis  Delafield,  New  York. 
Reginald  H.  Fitz,  Boston. 
James  W.  Holland,  Philadelphia. 
Henry  M.  Lyman,  Chicago. 
William  Osier,  Baltimore. 


Dr.  William  Pepper,  Philadelphia. 

W.  Gilman  Thompson,  New  York. 
W.  H.  Welch,  Baltimore. 
James  T.  Whittaker,  Cincinnati. 
James  C.  Wilson,  Philadelphia. 
Horatio  C.  Wood,  Philadelphia. 


"  We  reviewed  the  first  volume  of  this  work,  and  said  :  '  It  is  undoubtedly  one  of  the  best 
text-books  on  the  practice  of  medicine  which  we  possess.'  A  consideration  of  the  second 
and  last  volume  leads  us  to  modify  that  verdict  and  to  say  that  the  completed  work  is,  in  our 
opinion,  the  best  of  its  kind  it  has  ever  been  our  fortune  to  see.  It  is  complete,  thorough, 
accurate,  and  clear.  It  is  well  written,  well  arranged,  well  printed,  well  illustrated,  and  well 
bound.    It  is  a  model  of  what  the  modern  text-book  should  be." — Ne7u  York  Medical  yournal. 

"  A  library  upon  modern  medical  art.  The  work  must  promote  the  wider  diffusion  of 
sound  knowledge." — American  Lancet. 

"  A  trusty  counsellor  for  the  practitioner  or  senior  student,  on  which  he  may  implicitly 
rely." — Edinburgh  Medical  jfournal. 


CATALOGUE    OF  MEDICAL    WORKS. 


For  Sale  by  Subscription. 


AN   AMERICAN  TEXT-BOOK  OF  THE  DISEASES  OF  CHIL- 
DREN.    By  American  Teachers.     Edited  by  Louis  Starr,  M.D., 
assisted  by  Thompson  S.  Westcott,  M.  D.     In  one  handsome  royal-Svo 
•  volume  of  1190  pages,  profusely  illustrated  with  wood-cuts,  half-tone  and 
colored  plates.    Net  Prices  :  Cloth, $7.00;  Sheep,$8.oo;  Half  Russia,  ;^9.oo. 

The  plan  of  this  work  embraces  a  series  of  original  articles  written  by  some 
sixty  well-known  paediatrists,  representing  collectively  the  teachings  of  the  most 
prominent  medical  schools  and  colleges  of  America.  The  work  is  intended  to 
be  a  PRACTICAL  book,  suitable  for  constant  and  handy  reference  by  the  practi- 
tioner and  the  advanced  student. 

One  decided  innovation  is  the  large  number  of  authors,  nearly  every  article 
being  contributed  by  a  specialist  in  the  line  on  which  he  writes.  This,  while 
entailing  considerable  labor  upon  the  editors,  has  resulted  in  the  publication  of 
a  work  thoroughly  new  and  abreast  of  the  times. 

Especial  attention  has  been  given  to  the  latest  accepted  teachings  upon  the 
etiology,  symptoms,  pathology,  diagnosis,  and  treatment  of  the  disorders  of  chil- 
dren, with  the  introduction  of  many  special  formulae  and  therapeutic  procedures. 

Special  chapters  embrace  at  unusual  length  the  Diseases  of  the  Eye,  Ear, 
Nose  and  Throat,  and  the  Skin  ;  while  the  introductory  chapters  cover  fully  the 
important  subjects  of  Diet,  Hygiene,  Exercise,  Bathing,  and  the  Chemistry  of 
Food.  Tracheotomy,  Intubation,  Circumcision,  and  such  minor  surgical  pro- 
cedures coming  within  the  province  of  the  medical  practitioner  are  carefully 
considered. 

COXTRIBrTORS : 


Dr.  S.  S.  Adams,  Washington. 

John  Ashhurst,  Jr.,  Philadelphia. 
A.  D.  Blackader,  Montreal,  Canada. 
Dillon  Brown,  New  York. 
Edward  IM.  Buckingham,  Boston. 
Charles  W.  Burr,  Philadelphia. 
W.  E.  Casselberry,  Chicago. 
Kenry  Dwight  Chapin,  New  York. 
W.  S.  Christopher,  Chicago. 
Archibald  Church,  Chicago 
Floyd  M.  Crandall,  New  York. 
Andrew  F.  Currier,  New  York. 
Roland  G.  Curtin,  Philadelphia 
J.  M.  DaCosta,  Philadelphia. 
I.  N.  Danforth,  Chicago. 
Edward  P.  Davis,  Philadelphia. 
John  B.  Deaver,  Philadelphia. 
G.  E.  de  Schweinitz.  Philadelphia. 
John  Doming,  New  York. 
Charles  Warrington  Earle,  Chicago. 
Wm.  A.  Edwards,  San  Diego,  Cal. 
F.  Forchheimer,  Cincinnati. 
J.  Henry  Fruitnight,  New  York. 
Landon  Carter  Gray,  New  York. 
J.  P.  Crozer  Griffith.  Philadelphia. 
W.  A.  Hardaway.  St.  Louis. 
M.  P    Hatfield,  Chicago. 
Barton  Cooke  Hirst,  Philadelphia. 
H.  Illoway,  Cincinnati. 
Henry  Jackson,  Boston. 
Charles  G.  Jennings,  Detroit. 
Henry  Koplik,  New  York. 


Dr.  Thomas  S.  Latimer,  Baltimore. 
Albert  R.  Leeds,  Hoboken,  N.  J. 
J.  Hendrie  Lloyd,  Philadelphia. 
George  Roe  Lockwood,  New  York. 
Henry  AL  Lyman,  Chicago. 
Francis  T.  Miles,  Baltimore. 
Charles  K.  Mills,  Philadelphia. 
John  H.  Musser,  Philadelphia. 
Thomas  R.  Neilson,  Philadelphia. 
W.  P.  Northrup,  New  York. 
William  Osier,  Baltimore. 
Frederick  A.  Packard,  Philadelphia. 
William  Pepper,  Philadelphia. 
Frederick  Peterson,  New  York. 
W.  T.  Plant,  Syracuse,  New  York. 
William  J\L  Powell,  Atlantic  City. 
B.  Alexander  Randall,  Philadelphia. 
Edward  O.  Shakespeare,  Philadelphia. 
F.  C.  Shattuck,  Boston. 
J.  Lewis  Smith,  New  York. 
Louis  Starr,  Philadelphia. 
]\L  Allen  Starr,  New  York. 
J.  Madison  Taylor,  Philadelphia. 
Charles  W.  Townsend,  Boston. 
James  Tyson,  Philadelphia. 
W.  S.  Thayer,  Baltimore. 
Victor  C.  Vaughan,  Ann  Arbor,  Mich. 
Thompson  S.  Westcott,  Philadelphia. 
Henry  R.  Wharton,  Philadelphia. 
J.  William  White,  Philadelphia. 
J.  C.  Wilson,  Philadelphia. 


JV.   B.   SAUNDERS' 


For  Sale  by  Subscrii>tion. 


AN   AMERICAN   TEXT-BOOK  OF  GYNECOLOGY,  MEDICAL 
AND   SURGICAL,   for  the  use  of   Students    and    Practitioners. 

Edited  by  J.  M.  Baluv,  M.  D.  Forming  a  handsome  royal-octavo  volume, 
with  360  illustrations  in  text  and  37  colored  and  half-tone  plates.  Prices: 
Cloth,  ^6.00  net;  Sheep,  ^7.00  net;   Half  Russia,  ^8.00  net. 

In  this  volume  all  anatomical  descriptions,  excepting  those  essential  to  a  clear 
understanding  of  the  text,  have  been  omitted,  the  illustrations  being  largely  de- 
pended upon  to  elucidate  the  anatomy  of  the  parts.  This  work,  which  is 
thoroughly  practical  in  its  teachings,  is  intended,  as  its  title  implies,  to  be  a 
working  text-book  for  physicians  and  students.  A  clear  line  of  treatment  has 
been  laid  down  in  every  case,  and  although  no  attempt  has  been  made  to  dis- 
cuss mooted  points,  still  the  most  important  of  these  have  been  noted  and  ex- 
plained. The  operations  recommended  are  fully  illustrated,  so  that  the  reader, 
having  a  picture  of  the  procedure  described  in  the  text  under  his  eye,  cannot  fail 
to  grasp  the  idea.  All  extraneous  matter  and  discussions  have  been  carefully 
excluded,  the  attempt  being  made  to  allow  no  unnecessary  details  to  cumber 
the  text.  The  subject-matter  is  brought  up  to  date  at  every  point,  and  the 
work  is  as  nearly  as  possible  the  combined  opinions  of  the  ten  specialists  who 
figure  as  the  authors. 

The  work  is  well  illustrated  throughout  with  wood-cuts,  half-tone  and 
colored  plates,  mostly  selected  from  the  authors'  private  collections. 


COXTRIBFTORS : 


Dr.  Henry  T.  Byford. 
John  M.  Baldy. 
Edwin  Cragin. 
J.  H.  Etheridge. 
William  Goodell. 


Dr.  Howard  A.  Kelly. 
Florian  Krug. 
E.  E.  Montgomery. 
William  R.  Pryor. 
George  M.  Tuttle. 


"  The  most  notable  contribution  to  gynecological  literature  since  1887,  ....  and  the  most 
complete  exponent  of  gynecology  which  we  have.  No  subject  seems  to  have  been  neglected, 
....  and  the  gynecologist  and  surgeon,  and  the  general  practitioner  who  has  any  desire 
to  practise  diseases  of  women,  will  find  it  of  practical  value.  In  the  matter  of  illustrations 
and  plates  the  book  surpasses  anything  we  have  seen." — Boston  Medical  and  Surgical 
yournal. 

"  A  valuable  addition  to  the  literature  of  Gynecology'.  The  writers  are  progressive, 
aggressive,  and  earnest  in  their  convictions." — Medical  News,  Philadelphia. 

"  A  thoroughly  modern  text-book,  and  gives  reliable  and  well-tempered  advice  and  in- 
struction."— Edinburgh  Medical  Journal. 

"  The  harmony  of  its  conclusions  and  the  homogeneity  of  its  style  give  it  an  individuality 
which  suggests  a  single  rather  than  a  multiple  authorship." — Annals  of  Surgery. 

'I  It  must  command  attention  and  respect  as  a  worthy  representation  of  our  advanced 
clinical  teaching." — American  Journal  of  Medical  Sciences. 


CATALOGUE    OF  MEDICAL    WORKS. 


For  Sale  by  Subscription. 


DISEASES  OF  THE  EYE.  A  Handbook  of  Ophthalmic  Prac- 
tice. By  G.  E.  DE  ScHWEiNlTZ,  M.  D.,  Professor  of  Diseases  of  the  Eye, 
Philadelphia  Polyclinic ;  Professor  of  CHnical  Ophthalmology,  Jefferson 
Medical  College,  Philadelphia,  etc.  Forming  a  handsome  royal-octavo 
volume  of  more  than  600  pages,  with  over  200  fine  wood-cuts,  many  of 
which  are  original,  and  2  chromo-lithographic  plates.  Prices :  Cloth, 
$4.00  net;  Sheep,  $5.00  net;   Half  Russia,  $5.50  net. 

The  object  of  this  work  is  to  present  to  the  student  and  practitioner  who  is 
beginning  work  in  the  fields  of  ophthalmology  a  plain  description  of  the  optical 
defects  and  diseases  of  the  eye.  To  this  end  special  attention  has  been  paid 
to  the  clinical  side  of  the  question;  and  the  method  of  examination,  the  symp- 
tomatology leading  to  a  diagnosis,  and  the  treatment  of  the  various  ocular  defects 
have  been  brought  into  special  prominence.  The  general  plan  of  the  book  is 
eminently  practical.  Attention  is  called  to  the  large  number  of  illustrations 
(nearly  one-third  of  which  are  new),  which  will  materially  facilitate  the  thoroagh 
understanding  of  the  subject. 

"For  the  student  and  practitioner  it  is  the  best  single  volume  at  present  published." — 
Medical  Nezvs,  Philadelphia. 

"  A  most  complete  and  sterling  presentation  of  the  present  status  of  modern  knowledge 
concerning  diseases  of  the  eye." — Medical  Age. 

"  Pre-eminently  a  book  for  those  wishing  a  clear  yet  comprehensive  and  full  knowledge 
of  the  fundamental  truths  which  underlie  and  govern  the  practice  of  ophthalmology." — Med- 
ical and  Surgical  Reporter. 

"At  once  comprehensive  and  thoroughly  up  to  date." — Hospital  Gazette  (London). 

PROFESSIONAL.  OPIXIOXS. 

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practitioner  in  a -rare  degree.     I  am  satisfied  that  unusual  success  awaits  it." 

William  Pepper,  M.  D,, 
Provost  and  Professor  of  Theory  and  Practice  of  Medicine  and  Clinical  Medicine 
in  the  University  of  Pennsylvania . 

"  Contains  in  concise  and  reliable  form  the  accepted  views  of  Ophthalmic  Science." 

\ViLLi.\M  Thomson,  M.  D., 
Professor  of  Ophthalmology,  feffcrsoti  Medical  College,  Philadelphia,  Pa. 

"  Contains  in  the  most  attractive  and  easily  understood  form  just  the  sort  of  knowledge 
which  is  necessary  to  the  intelligent  practice  of  general  medicine  and  surgery'." 

J.  William  White,  M.  D., 

Professor  of  Clinical  Surgery  in  the  University  of  Pennsylvania. 

"A  very  reliable  guide  to  the  study  of  eye  diseases,  presenting  the  latest  facts  and  newest 
ideas." 

Swan  M.  Burnett,  M.  D., 

Professor  of  Ophthalmology  and  Otology,  Medical  Department  Univ.  of  Georgetown, 

Washington,  D.  C. 


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MEDICAL  DIAGNOSIS.  By  Dr.  Oswald  Vikrordt,  Professor  of 
Medicine  at  the  University  of  Heidelberg.  Translated,  with  additions, 
from  the  Second  Enlarged  German  Edition,  with  the  author's  permission, 
by  Francis  H.  Stuart,  A.  M.,  M.  D.  Third  and  Revised  Edition.  In 
one  handsome  royal-octavo  volume  of  700  pages,  178  fine  wood-cuts  in 
text,  many  of  which  are  in  colors  Prices  :  Cloth,  $4.00  net;  Sheep,  ^^5.00 
net;   Half  Russia,  $5.50  net. 

In  this  work,  as  in  no  other  hitherto  published,  are  given  full  and  accurate 
explanations  of  the  phenomena  observed  at  the  bedside.  It  is  distinctly  a  clin- 
ical work  by  a  master  teacher,  characterized  by  thoroughness,  fulness,  and  accu- 
racy. It  is  a  mine  of  information  upon  the  points  that  are  so  often  passed  over 
without  explanation.  Especial  attention  has  been  given  to  the  germ-theory  as 
a  factor  in  the  origin  of  disease. 

This  valuable  work  is  now  published  in  German,  English,  Russian,  and 
Italian.  The  issue  of  a  third  American  edition  within  two  years  indicates  the 
favor  with  which  it  has  been  received  by  the  profession. 

"  Rarely  is  a  book  published  with  which  a  reviewer  can  find  so  little  fault  as  with  the 
volume  before  us.  All  the  chapters  are  full,  and  leave  little  to  be  desired  by  the  reader. 
Each  particular  item  in  the  consideration  of  an  organ  or  apparatus,  which  is  necessary  to 
determine  a  diagnosis  of  any  disease  of  that  organ,  is  mentioned;  nothing  seems  forgotten. 
The  chapters  on  diseases  of  the  circulatorj'  and  digestive  apparatus  and  nervous  system  are 
especially  full  and  valuable.  Notwithstanding  a  few  minor  errors  in  translating,  which  are 
of  small  importance  to  the  accuracy  of  the  rest  of  the  volume,  the  reviewer  would  repeat  that 
the  book  is  one  of  the  best — probably  the  best — which  has  fallen  into  his  hands.  An  excel- 
lent and  comprehensive  index  of  nearly  one  hundred  pages  closes  the  volume." — University 
Medical  Magazine,  Philadelphia. 

"Thorough  and  exact The  author  has  rendered  no  mean  service  to  medicine  in 

having  prepared  a  work  which  proves  as  useful  to  the  teacher  as  to  the  student  and  prac- 
titioner."—  The  Lancet  (London). 

PROFESSIONAL,   OPINIONS. 

"  One  of  the  most  valuable  and  useful  works  in  medical  literature." 

Alexander  J.  C.  Skene,  M.  D., 
Dean  of  the  Long  Island  College  Hospital,  and  Professor  of  the  Medical  and  Surgical 

Diseases  of  Wovten. 

"  Indispensable  to  both  '  students  and  practitioners.'  " 

F.  MiNOT,  M.  D., 
Hersey  Professor  of  Theory  and  Practice  of  Medicine,  Harvard  University. 

"  It  is  very  well  arranged  and  very  complete,  and  contains  valuable  features  not  usually 
foimd  in  the  ordinary  books." 

J.  H.  MussER,  M.  D., 
Assistant  Professor  Clinical  Medicine,  University  of  Pennsyh<ania. 

"  One  of  the  most  valuable  works  now  before  the  profession,  both  for  study  and  reference." 

N.  S.  Davis,  M.  D., 

Professor  qf  Principles  and  Practice  of  Medicine  and  Clinical  Medicitte,  Chicago 

Medical  College. 


CATALOGUE    OF  MEDICAL    WORKS. 


For  Sale  by  Subscription. 

A  NEW  PRONOUNCING  DICTIONARY  OF  MEDICINE,  with 
Phonetic  Pronunciation,  Accentuation,  Etymology,  etc.  By  John 
M.  Keating,  M.  D.,  LL.D.,  Fellow  of  the  College  of  Physicians  of  Phila- 
delphia; Vice-President  of  the  American  Psediatric  Society;  Ex-President 
of  the  Association  of  Life  Insurance  Medical  Directors ;  Editor  "  Cyclo- 
paedia of  the  Diseases  of  Children,"  etc.;  and  Henry  Hamilton,  author 
of  "A  New  Translation  of  Virgil's  /Eneid  into  English  Rhyme;"  co- 
author of  "  Saunders'  Medical  Lexicon,"  etc. ;  with  the  Collaboration  of 
J.  Chalmers  DaCosta,  M.  D.,  and  Frederick  A.  Packard,  M.  D. 
W.ith  an  Appendix  containing  important  Tables  of  Bacilli,  Micrococci, 
Leucomaines,  Ptomaines,  Drugs  and  Materials  used  in  Antiseptic  Sur- 
gery, Poisons  and  their  Antidotes,  Weights  and  Measures,  Thermometric 
Scales,  New  Official  and  Unofficial  Drugs,  etc.  Forming  one  very 
attractive  volume  of  over  800  pages.  Second  Revised  Edition.  Prices : 
Cloth,  $5.00  net;  Sheep,  S6.00  net;  Half  Russia,  $6.50  net.  With 
Denison's  Patent  Index  for  Ready  Reference. 

PROFESSIOXAL,   OPIXIOXS. 
"  I  am  much  pleased  with  Keating's  Dictionary,  and  shall  take  pleasure  iu  recommending 
it  to  my  classes." 

Henky  M.  Lyman,  M.  D.. 
Professor  of  Principles  and  Practice  of  Medicine,  Rush  Medical  College,  Chicago,  III. 
''  I  am  convinced  that  it  will  be  a  very  valuable  adjunct  to  my  sludy-table,  convenient  in 
size  and  sufficiently  full  for  ordinary  use." 

C.   A.  LiNDSLEY.  M.   D., 

Professor  of  Theory  and  Practice  of  Medicine,  Medical  Dept.  Yale  University : 

Secretary  Connecticut  State  Board  of  Health,  Nejv  Haven,  Conn 

"I  will  point  out  to  my  classes  the  many  good  features  of  this  book  as  compared  wilh 
others,  which  will,  I  am  sure,  make  it  very  popular  with  students." 

John  Ckonyn,  M.  D.,  LL.D.. 
Professor  of  Principles  and  Practice  of  Medicine  and  Clinical  Medicine  : 

President  of  the  Faculty,  Medical  Dept.  Niagara  University,  Buffalo,  N.  Y. 

AUTOBIOGRAPHY  OF  SAMUEL  D.  GROSS.  M.  D..  Emeritus  Pro- 
fessor of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia,  with 
Reminiscences  of  His  Times  and  Contemporaries.      Edited  by  his  sons, 
Samuel  W.  Gross,  M.  D.,  LL.D.,  late  Professor  of  Principles  of  Surgery 
and  of  Clinical  Surgery  in  the  Jefferson  Medical  College,  and  A.  Haller 
Gross,  A.  M.,  of  the  Philadelphia  Bar.     Preceded  by  a  Memoir  of  Dr. 
Gross,  by  the  late  Austin  Flint,  M.  D.,  LL.D.     In  two  handsome  volumes, 
each  containing  over  400  pages,  demy  8vo,  extra  cloth,  gilt  tops,  with  fine 
Frontispiece  engraved  on  steel.     Price,  S5.00  net. 
This  autobiography,  which  was  continued  by  the  late  eminent  surgeon  until 
within  three  months  of  his  death,  contains  a  full  and  accurate  history  of  his 
early  struggles,  trials,  and  subsequent  successes,  told  in  a  singularly  interesting 
and'charming  manner,  and  embraces  short  and  graphic  pen-portraits  of  many 
of  the  most  distinguished  men — surgeons,  physicians,  divines,  lawyers,  states- 
men, scientists,  etc. — with  whom  he  was  brought  in  contact  in  America  and  in 
Europe  ;  the  wjiole  forming  a  retrospect  of  more  than  three-quarters  of  a  century. 


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AN  AMERICAN  TEXT-BOOK  OF  OBSTETRICS.  By  American 
Teachers.  By  Richard  C.  Norris,  A.  M.,  M.  D.;  James  H.  Etheridge, 
M.  D. ;  Chauncey  D.  Palmer.  M.  D. ;  Howard  A.  Kelly,  M.  D. ;  Charles 
Jewett,  M.  D.;  Henry  J.  Garrigues,  M.  D. ;  Barton  Cooke  Hirst,  M.  D. ; 
Theophilus  Parvin,  M.  U. ;  George  A.  Piersol,  M.  D. ;  Edward  P.  Davis, 
M.  D. ;  Charles  Warrington  Earle,  M.  D. ;  Robert  L.  Dickinson,  M.  D. ; 
Edward  Reynolds,  M.  D. ;  Henry  Schwarz,  M.  D. ;  and  James  C.  Cam- 
eron, M.  D.  In  one  very  handsome  imperial-octavo  volume,  with  a  large 
number  of  original  illustrations,  including  full-page  plates,  and  uniform 
with  "  The  American  Text-Book  of  Gynecology."    (In  active  preparation.) 

Such  an  array  of  well-known  teachers  is  a  sufficient  guarantee  of  the  high 
character  of  the  work,  and  it  gives  the  assurance  that  this  work  will  have  the 
same  measure  of  success  awarded  it  as  has  attended  the  recent  publication  of 
its  companion  volume,  "  The  American  Text-Book  of  Gynecology."  The  illus- 
trations will  receive  the  most  minute  attention  ;  the  cuts  interspersed  throughout 
the  text,  and  the  full -page  plates,  which  will  reflect  the  highest  attainments  of 
the  artist  and  engraver,  will  appeal  at  once  to  the  eye  as  well  as  to  the  mind 
of  the  student  and  practitioner. 

AN  AMERICAN  TEXT-BOOK  OF  PHYSIOLOGY.  By  American 
Teachers.  Edited  by  William  H.  Howell,  Ph.  D.,  M.  D.,  Professor 
of  Physiology,  Johns  Hopkins  University.  With  the  collaboration  of  such 
eminent  specialists  as  Henry  P.  Bowditch,  M.  D. ;  John  G.  Curtis,  M.  D. ; 
Henry  H.  Donaldson,  M.  D. ;  Frederick  S.  Lee,  M.  D. ;  Warren  P.  Lom- 
bard, A.  B.,  M.  D. ;  Graham  Lusk,  Ph.  D.  ;  Henry  Sewall,  M.  D. ;  Edward 
T.  Reichert,  M.  D. ;  Joseph  W.  Warren,  M.  D.  In  one  imperial-octavo 
volume  (with  a  large  number  of  original  illustrations),  uniform  with  The 
American  Text-Books  of  "Surgery,"  "Practice,"  "Gynecology,"  etc. 
(In  preparation  for  early  publication.) 

This  will  be  the  most  notable  attempt  yet  made  in  this  country  to  combine  in 
one  volume  the  entire  subject  of  Human  Physiology  by  well-known  teachers 
who  have  given  especial  study  to  that  part  of  the  subject  upon  which  they  will 
write.  The  completed  work  will  represent  the  present  status  of  the  science  of 
Physiology,  and  in  particular  from  the  standpoint  of  the  student  of  medicine 
and  the  medical  practitioner.  Illustrations  largely  drawn  from  original  sources 
will  be  used  freely  throughout  the  text. 

AN  AMERICAN  TEXT-BOOK  OF  APPLIED  THERAPEUTICS. 
By  American  Teachers.     (In  preparation.) 

AN    AMERICAN    TEXT-BOOK    OF    NURSING.      By   American 
Teachers.     (In  preparation.) 


CATALOGUE    OF  MEDICAL    WORKS. 


A  SYLLABUS  OF  GYNECOLOGY,  arranged  in  conformity  with 
The  American  Text-Book  of  Gynecology.  By  J.  W.  Long,  M.  D., 
Professor  of  Diseases  of  Women  and  Children,  Medical  College  of  Vir- 
ginia, etc.     (Preparing.) 

Based  upon  the  teaching  and  methods  laid  down  in  the  larger  work,  this  will 
not  only  be  useful  as  a  supplementary  volume,  but  to  those  who  do  not  already 
possess  the  text-book  it  will  also  have  an  independent  value  as  an  aid  to  the 
practitioner  in  gynecological  work,  and  to  the  student  as  a  guide  in  the  lecture- 
room,  as  the  sul)ject  is  presented  in  a  manner  at  once  systematic,  clear,  succinct, 
and  practical. 


TEMPERATURE   CHART.     Prepared  by   D.  T.  Laine,  M.  D.      Size 
8x  13^  inches.     Price,  per  pad  of  25  charts,  50  cents. 

A  conveniently  arranged  chart  for  recording  Temperature,  with  columns  for 
daily  amounts  of  Urinary  and  Fecal  Excretions,  Food,  Remarks,  etc.  On  the 
back  of  each  chart  is  given  in  full  the  method  of  Brand  in  the  treatment  of 
Typhoid  Fever. 


THE  NURSE'S  DICTIONARY  of  Medical  Terms  and  Nursing 
Treatment,  containing  Definitions  of  the  Principal  Medical  and  Nursing 
Terms,  Abbreviations,  and  Physiological  Names,  and  Descriptions  of  the 
Instruments,  Drugs,  Diseases,  Accidents,  Treatments,  Operations,  Foods, 
Appliances,  etc.  encountered  in  the  ward  or  in  the  sick-room.  Compiled 
for  the  use  of  nurses.  By  HoNNOR  Morten,  author  of  "  How  to  Become 
a  Nurse,"  "  Sketches  of  Hospital  Life,"  etc.  Second  and  enlarged  edi- 
tion.    i6mo,  140  pages.     Price,  Cloth,  $1.00. 

This  little  volume  is  intended  for  use  merely  as  a  small  reference -book  which 
can  be  consulted  at  the  bedside  or  in  the  ward.  It  gives  sufficient  explanation 
to  the  nurse  to  enable  her  to  comprehend  a  case  until  she  has  leisure  to  look 
up  larger  and  fuller  works  on  the  subject. 

"  Should  be  at  the  disposal  of  everj'  nurse." — Birmi7igha77i  Medical  Review. 

"Maintains  its  reputation  for  brevity  and  simplicity." — Hahncjiianniaji  Monthly. 

'"Though  ostensibly  for  professional  nurses,  contains  in  a  compact  form  just  such  infor- 
mation as  almost  every  intelligent  man  would  like  to  have  at  hand  in  these  days  when 
the  interest  in  all  matters  of  sanitation  and  medicine  has  become  so  great." — Medical 
Examiner. 

"  A  book  which  every  progressive  nurse  must  have." — Medical  World. 

"This  little  volume  is  almost  indispensable  in  the  training  school  and  in  the  library  of  the 
nurse." — New  York  Medical  Times. 


lO  M^.   B.   SAUNDERS' 


SURGICAL  PATHOLOGY  AND  THERAPEUTICS.  By  J.  Col- 
lins Warrkn,  M.  J).,  Professor  of  Surgery,  Harvard  Medical  School,  etc. 
In  one  very  handsome  octavo  volume  of  over  800  pages,  with  135  illus- 
trations, T,2>  of  which  are  chromolithographs,  and  all  of  which  are  drawn 
from  original  specimens.     (Passing  through  the  press.) 

Covering  as  it  does  the  entire  held  of  Surgical  Pathology  and  Surgical  Thera- 
peutics by  an  acknowledged  authority,  the  publisher  is  contident  that  the  work 
will  rank  as  a  standard  authority  on  the  subject  of  which  it  treats.  Particular 
attention  has  been  paid  to  Bacteriology  and  Surgical  Bacteria  from  the  stand- 
point of  recent  investigations,  and  the  chromo-lithographic  plates  in  their  fidelity 
to  nature  and  in  scientific  accuracy  have  hitherto  been  unapproached. 

DISEASES  OF  WOMEN.  By  Henry  J.  Garrigues,  A.M.,  M.D., 
Professor  of  Obstetrics  in  the  New  York  Post-Graduate  Medical  School 
and  Hospital;  Gynecologist  to  St.  Mark's  Hospital  and  to  the  German 
Dispensary,  etc.,  New  York  City.  In  one  very  handsome  octavo  volume 
of  about  700  pages,  illustrated  by  numerous  wood-cuts  and  colored  plates. 
Prices  :  Cloth,  $4.00  net;   Sheep,  ^5.00  net. 

A  PRACTICAL  work  on  gynecology  for  the  use  of  students  and  practitioners, 
written  in  a  terse  and  concise  manner.  The  importance  of  a  thorough  know- 
ledge of  the  anatomy  of  the  female  pelvic  organs  has  been  fully  recognized  by 
the  author,  and  considerable  space  has  been  devoted  to  the  subject.  The  chap- 
ters on  Operations  and  on  Treatment  are  thoroughly  modern,  and  are  based 
upon  the  large  hospital  and  private  practice  of  the  author.  The  text  is  eluci- 
dated by  a  large  number  of  illustrations  and  colored  plates,  many  of  them  being 
original,  and  forming  a  complete  atlas  for  studying  embi'vology  and  the  anatomy 
of  \}cs.t  female  genitalia,  besides  exemplifying,  whenever  needed,  morbid  condi- 
tions, instruments,  apparatus,  and  operations. 

EXCERPT   OF   CONTENTS. 

Development  of  the  Female  Genitals. — Anatomy  of  the  Female  Pelvic  Organs. — Phys- 
iology.— Puberty. — Menstruation  and  Ovulation. — Copulation. — Fecundation. — The  Climac- 
teric.— Etiology  in  General. — Examinations  in  General. — Treatment  in  General — Abnormal 
Menstruation  and  Metrorrhagia. — -Leucorrhea. — Diseases  of  the  Vulva.— Diseases  of  the 
Perineum. — Diseases  of  the  Vagina. — Diseases  of  the  Uterus. — Diseases  of  the  Fallopian 
Tubes. — Diseases  of  the  Ovaries. — Diseases  of  the   Pelvis. — Sterility. 

The  reception  accorded  to  this  work  has  been  most  flattering.  In  the  short 
period  which  has  elapsed  since  its  issue  it  has  been  adopted  and  recommended 
as  a  text-book  by  more  than  60  of  the  Medical  Schools  and  Universities  of  the 
United  States  and  Canada. 

"One  of  the  best  text-books  for  students  and  practitioners  which  has  been  published  in 
the  English  language;  it  is  condensed,  clear,  and  comprehensive.  The  profound  learning 
and  great  clinical  experience  of  the  distinguished  author  find  expression  in  this  book  in  a 
most  attractive  and  instructive  form.  Young  practitioners,  to  whom  experienced  consultants 
may  not  be  available,  will  find  in  this  book  invaluable  counsel  and  help." 

Thad.  a.  Reamy,  M.  D.,  LL.D., 

Professor  of  Clinical  Gynecology,  Medical  College  of  Ohio  :   Gynecologist  to  the  Good 

Samaritan  and  Cincinnati  Hospitals. 


Practical,  Exhaustive,  Authoritative. 


SAUNDERS' 

NEW  AID  SERIES  OF  MANUALS 


FOR 


Students  and  Practitioners. 


Mr.  Saunders  is  pleased  to  announce  as  in  active  preparation  his  NEW 
AID  SERIES  OF  MANUALS  for  Students  and  Practitioners.  As 
publisher  of  the  Standard  Series  of  Question  Compends,  and  through  in- 
timate relations  with  leading  members  of  the  medical  profession,  Mr.  Saunders 
has  been  enabled  to  study  progressively  the  essential  desiderata  in  practical 
"self-helps"  for  students  and  physicians. 

This  study  has  manifested  that,  while  the  published  "  Question  Compends"' 
earn  the  highest  appreciation  of  students,  whom  they  serve  in  reviewing  their 
studies  preparatory  to  examination,  there  is  special  need  of  thoroughly  reliable 
handbooks  on  the  leading  branches  of  Medicine  and  Surgeiy,  each  subject 
being  compactly  and  authoritatively  written,  and  exhaustive  in  detail,  without 
the  introduction  of  cases  and  foreign  subject-matter  which  so  largely  expand 
ordinary  text-books. 

The  Saunders  Aid  Series  will  not  merely  be  condensations  from 
present  literature,  but  will  be  ably  written  by  well-known  authors 
and  practitioners,  most  of  them  being  teachers  in  representative 
American  Colleges.  This  nexo  series.,  therefore,  will  form  an  admirable 
collection  of  advanced  lectures,  which  will  be  invaluable  aids  to  students  in 
reading  and  in  comprehending  the  contents  of  "  recommended  "  works. 

Each  Manual  will  further  be  distinguished  by  the  beauty  of  the  netu  type ; 
by  the  quality  of  the  paper  and  printing;  by  the  copious  use  of  illustrations; 
by  the  attractive  binding  in  cloth ;  and  by  the  extremely  low  price,  which 
will  uniformly  be  $1.25  per  volume. 

II 


SAUNDERS'  NEW  AID  SERIES  OF  MANUALS. 


VOLUMES  NOW  EEADY. 


PHYSIOLOGY.  By  Joseph  Howard  Raymond,  A.  M.,  M.  D.,  Trofessor 
of  riiysiology  and  Hyp;iene  ami  Lecturer  on  Gynecology  in  the  Long 
Island  College  Hospital,  etc.     Price,  $1.2$  net. 

SURGERY,  General  and  Operative.  By  John  Chalmers  DaCosta, 
M.  D,,  Demonstrator  of  Surgery,  Jefifcrson  Medical  College,  Philadelphia, 
eic.     DouI)le  number.     Price,  ^2.50  net. 

DOSE-BOOK  AND  MANUAL  OF  PRESCRIPTION-WRITING. 

Jjv   E.   (2-   'rnoKNToN,    M.  D.,   Demonstrator    of    Therapeutics,  Jeffer.-on 
Medical  College,  Philadelphia.     Price,  $1.25  net. 

MEDICAL  JURISPRUDENCE.  By  Henry  C.  Chapman,  M.  D.,  Pro- 
fessor of  Institutes  of  Medicine  and  Medical  Jurisprudence  in  the  Jeffer- 
son Medical  College  of  Philadelphia,  etc      Price,  $1.25  net. 

SURGICAL  ASEPSIS.  By  Carl  Beck,  M.D.,  Surgeon  to  St.  Mark's 
Hospital  and  to  the  German  Poliklinik  ;  Instructor  in  Surgery,  New  York 
Post-Graduate  Medical  School,  etc.     Price,  ^1.25  net. 


VOLUMES  IN  PKEPARATION  TOE  EAELY  PUBLICATION. 

OBSTETRICS.  By  W.  A.  Newman  Borland,  M.  D.,  Demonstrator  of 
Obstetrics,  University  of  Pennsylvania;  Chief  of  Gynecological  Dispen- 
sary, Pennsylvania  Hospital ;  Member  of  Philadelphia  Obstetrical  Society, 
etc.     Price,  $1.25  net. 

MATERIA  MEDICA  AND  THERAPEUTICS.  By  Henry  A. 
Griffin,   A.  B.,  M.  D.,  Assistant   Physician  to  the   Roosevelt   Hospital, 

Out-patient  Department,  New  York  City.     Price,  $1.25  net. 

SYPHILIS  AND  THE  VENEREAL  DISEASES.  By  James 
Nevins  Hyde,  M.  D.,  Professor  of  Skin  and  Venereal  Diseases  in  Rush 
Medical  College,  Chicago.     Double  number.     Price,  $2.50  net. 

NERVOUS  DISEASES.  By  Charles  W.  Burr,  M.  D.,  Clinical  Pro- 
fessor of  Nervous  Diseases,  Medico-Chirurgical  College,  Philadelphia, 
etc.     Price,  $1.25  net. 

PRACTICE  OF  MEDICINE.  By  George  Roe  Lockwood,  M.  D., 
Professor  of  Practice  in  the  Woman's  Medical  College  and  in  the  New 
York  Infirmary,  etc.     Double  number.     Price,  $2.50  net. 

NOSE  AND  THROAT.  By  D.  Braden  Kyle,  M.  D.,  Chief  Laryngol- 
ogist  to  St.  Agnes'  Hospital,  Philadelphia;  Instructor  in  Clinical  Micros- 
copy and  Assistant  Demonstrator  of  Pathology  in  the  Jefferson  Medical 
College,  etc.     Price,  ;?i.25  net. 

*:;:*  There  will  be  published  in  the  same  series,  at  close  intervals,  carefully-pre- 
pared works  on  the  subjects  of  Anatomy,  Gynecology.  Pathology,  Hygiene,  etc., 
by  prominent  specialists. 
12 


CATALOGUE    OF  MEDICAL    WORKS.  1 3 

Saunders^  ^ew  Aid  Series  of  Mdtiuals, 


A  MANUAL  OF  PHYSIOLOGY.  By  Joseph  H.  Raymond,  A.  M., 
^LD.,  Professor  of  Physiology  and  Hygiene  and  Lecturer  on  Gynecology 
in  the  Long  Island  College  Hospital ;  Director  of  Physiology  in  the  Hoag- 
land  Laboratory;  formerly  Lecturer  on  Physiology  and  Hygiene  in  the 
Brooklyn  Normal  School  for  Physical  Education ;  Ex-Vice-President  of 
the  American  Public  Health  Association ;  Ex-Health  Commissioner  City 
of  Brooklyn,  etc.     Illustrated.      Price,  Cloth,  Si. 25  net.     (Just  ready.) 

In  this  manual  the  author  has  endeavored  to  put  into  a  concrete  and  avail- 
able form  the  results  of  twenty  years'  experience  as  a  teacher  of  Physiology  to 
medical  students,  and  has  produced  a  work  for  the  student  and  practitioner, 
representing  in  a  concise  form  the  existing  state  of  Physiology  and  its  methods 
of  investigation,  based  upon  Comparative  and  Pathological  Anatomy,  Clinical 
Medicine,  Physics,  and  Chemistry,  as  well  as  upon  experimental  research. 


MANUAL  OF  SURGERY,  General  and  Operative.  By  John 
Chalmers  DaCosta,  M.  D.,  Demonstrator  of  Surgery,  Jefferson  Medical 
College,  Philadelphia;  Chief  Assistant  Surgeon,  Jefferson  Medical  College 
Hospital ;  Surgical  Registrar,  Philadelphia  Hospital,  etc.  One  very  hand- 
some volume  of  over  700  pages,  with  a  large  number  of  illustrations. 
(Double  number.)     Price,  Cloth,  S2.50  net. 


A  new  manual  of  the  Principles  and  Practice  of  Surger}-,  intended  to  meet 
the  demands  of  students  and  working  practitioners  for  a  medium-sized  work 
which  will  embody  all  the  newer  methods  of  procedure  detailed  in  the  larger 
text-books.  The  work  has  been  written  in  a  concise,  practical  manner,  and 
especial  attention  has  been  given  to  the  most  recent  methods  of  treatment. 
Illustrations  are  freely  used  to  elucidate  the  text. 


A  MANUAL  OF  OBSTETRICS.  By  W.  A.  Newman  Dorland, 
M.  D.,  Demonstrator  of  Obstetrics,  University  of  Pennsylvania;  Chief  of 
Gynecological  Dispensary,  Pennsylvania  Hospital ;  Member  of  Phila- 
delphia Obstetrical  Society,  etc.  Profusely  illustrated.  Price,  Cloth, 
$1.25  net.     (Preparing.) 

This  work,  which  is  thoroughly  practical  in  its  teachings,  is  intended,  as  its 
title  implies,  to  be  a  working  text-book  for  the  student  and  of  value  to  the 
practitioner  as  a  convenient  handbook  of  reference.  Although  concisely  writ- 
ten, nothing  of  importance  is  omitted  that  will  give  a  clear  and  succinct  know- 
ledge of  the  subject  as  it  stands  to-day.  Illustrations  are  freely  used  throughout 
the  text. 


14  W.   B.    SAUNDERS' 


Saunders'  Neiv  Aid  Series  of  Manuals. 

DOSE-BOOK  AND  MANUAL  OF  PRESCRIPTION-WRITING. 

By  E.  Q.  Thornton,  M.  D.,  Demonstrator  of  Therapeutics,  Jefferson 
Medical  College,  Philadelphia.      Illustrated.     Price,  Cloth,  ^1.25  net. 

But  little  attention  is  generally  given,  in  works  on  Materia  Medica  and  Thera- 
peutics, to  the  methods  of  combining  remedies  in  the  form  of  prescriptions,  and 
this  manual  has  l^een  written  especially  for  students  in  the  hope  that  it  may 
serve  to  give  a  thorough  and  comprehensive  knowledge  of  the  subject. 

The  work,  which  is  based  upon  the  last  (1890)  edition  of  the  Pharmacopceia, 
fully  covers  the  subjects  of  Weights  and  Measures,  Prescriptions  (form  of 
writing,  general  directions  to  pharmacist,  grammatical  construction,  etc.). 
Dosage,   Incompatibles,  Poisons,  etc. 

MEDICAL  JURISPRUDENCE  AND  TOXICOLOGY.     By  Henry 

C.  Chapman,  M.  D.,  Professor  of  Institutes  of  Medicine  and  Medical 
Jurisprudence  in  the  Jefferson  Medical  College  of  Philadelphia  ;  Member 
of  the  College  of  Physicians  of  Philadelphia,  of  the  Academy  of  Natural 
Sciences  of  Philadelphia,  of  the  American  Philosophical  Society,  and  of 
the  Zoological  Society  of  Philadelphia.  232  pages,  with  36  illustrations, 
some  of  which  are  in  colors.      Price,  $1.25  net. 

For  many  years  there  has  been  a  demand  from  members  of  the  medical  and 
legal  professions  for  a  medium-sized  work  on  this  most  important  branch  of 
medicine.  The  necessarily  proscribed  limits  of  the  work  permit  the  considera- 
tion only  of  those  parts  of  this  extensive  subject  which  the  experience  of  the 
author  as  coroner's  physician  of  the  city  of  Philadelphia  for  a  period  of  six 
years  leads  him  to  regard  as  the  most  material  for  practical  purposes. 

Particular  attention  is  drawn  to  the  illustrations,  many  being  produced  in 
colors,  thus  conveying  to  the  layman  a  far  clearer  idea  of  the  more  intricate 
cases. 

"The  salient  points  are  clearly  defined,  and  ascertained  facts  are  laid  down  with  a  clear- 
ness that  is  unequivocal." — St.  Louis  Medical  and  Surgical  yournal. 

"The  presentation  is  always  thorough,  the  text  is  liberally  interspersed  with  illustrations, 
and  the  style  of  the  author  is  at  once  pleasing  and  interesting." — Therapeutic  Gazette. 

"  One  that  is  not  overloaded  with  an  linnecessary  detail  of  a  large  amount  of  literature  on 
the  subject,  requiring  hours  of  research  for  the  essential  points  in  the  decision  of  a  question  ; 
that  contains  the  most  lucid  symptomatology  of  questionable  conditions,  tests  of  poisons,  and 
the  readiest  means  of  making  them — such  is  the  new  book  before  us." — T/ie  Sanitarian. 

A  GUIDE  TO  THE  BACTERIOLOGICAL  LABORATORY.     By 

Langdon  Frothingham,  M.  D.     Illustrated.     (In  preparation.) 

The  technical  methods  involved  in  bacteria-culture,  methods  of  staining,  and 
microscopical  study  are  fully  described  and  arranged  as  simply  and  concisely 
as  possible.     The  book  is  especially  intended  for  use  in  laboratory  work. 


CATALOGUE    OF  MEDICAL    WORKS.  1 5 


NURSING:     ITS    PRINCIPLES    AND    PRACTICE.       By    Isabkl 

Adams  Hamtton,  Graduate  of  the  New  York  Training  School  for 
Nurses  attached  to  Bellevu«  Hospital ;  Superintendent  of  Nurses  and 
Principal  of  the  Training  School  for  Nurses,  Johns  Hopkins  Hospital, 
Baltimore,  Md. ;  late  Superintendent  of  Nurses,  Illinois  Training  School 
for  Nurses,  Chicago,  111.  In  one  very  handsome  i2mo  volume  of  484. 
pages,  profusely  illustrated.     Price,  Cloth,  52.00  net. 

This  entirely  new  work  on  the  important  subject  of  nursing  is  at  once  com- 
prehensive and  systematic.  It  is  written  in  a  clear,  accurate,  and  readable 
style,  suitable  alike  to  the  student  and  the  lay  reader.  Such  a  work  has  long 
been  a  desideratum  with  those  intrusted  with  the  management  of  hospitals  and 
the  instruction  of  nurses  in  training  schools.  It  is  also  of  especial  value  to  the 
graduated  nurse  who  desires  to  acquire  a  practical  working  knowledge  of  the 
care  of  the  sick  and  the  hygiene  of  the  sick-room. 

The  author,  who  has  had  considerable  experience  as  superintendent  of 
training  schools  for  nurses  and  hospital  management,  brmgs  to  her  task  a  mind 
thoroughly  equipped  to  make  the  subject  attractive  as  well  as  scientific  and 
instructive. 

Thoroughly  attested  and  approved  processes  in  practical  nursing  only  have 
been  given,  particularly  in  antiseptic  surgery,  and  the  minutest  details  regard- 
ing the  nurse's  technique  have  I)een  explained. 

Illustrations  to  elucidate  the  text  have  been  used  freely  throughout  the  book, 
and  they  will  be  found  of  material  help  in  showing  the  forms  of  modern  appli- 
ances for  the  hospital  ward  and  sick-room,  the  registration  of  temperature,  daily 
records,  etc. 


METHODS  OF  PREVENTING  AND  CORRECTING  DEFORM- 
ITIES OF  THE  BONES  AND  JOINTS  :  A  Handbook  of  Prac- 
tical Orthopedic  Surgery.  By  H.  Augustus  Wilson,  M.  D  ,  Professor 
of  General  and  Orthopedic  Surgery,  Philadelphia  Polyclinic ;  Clinical  Pro- 
fessor of  Orthopedic  Surgery,  Jefterson  Medical  College,  Philadelphia,  etc. 
(In  preparation.) 

The  aim  of  the  author  is  to  provide  a  book  of  moderate  size,  containing 
comprehensive  details  that  will  enable  general  practitioners  to  understand  thor- 
oughly the  mechanical  features  of  the  many  forms  of  congenital  and  acquired 
deformities  of  the  bones  and  joints. 

The  mechanical  functions  that  are  impaired  will  be  considered  first  as  to  pre- 
vention as  of  primary  importance,  and  following  this  will  be  described  the 
methods  of  correction  that  have  been  proved  practical  by  the  author.  Ope- 
rative procedures  will  be  considered  from  a  mechanical  as  well  as  a  surgical 
standpoint.  Prominence  will  be  given  to  the  mechanical  requirements  for 
braces  and  artificial  limbs,  etc.,  with  description  of  the  methods  for  construct- 
ing the  simplest  forms,  whether  made  of  plaster  of  Paris,  felt,  leather,  paper, 
steel,  or  other  materials,  together  with  the  methods  of  readjustment  to  suit  the 
changes  occurring  during  the  progress  of  the  case.  A  very  large  number  of 
original  illustrations  will  be  used. 


1 6  fV.   B.   SAUNDERS' 


AN  OPERATION  BLANK,  with  Lists  of  Instruments,  etc.  re- 
quired in  Various  Operations.  Prepared  by  W.  W.  Keen,  M.  D., 
LL.D.,  Professor  of  Principles  of  Surgery  in  the  Jefferson  Medical  Col- 
lege, Philadelpliia.  Price  per  Pad,  containing  Blanks  for  fifty  operations, 
50  cents  net. 

A  convenient  blank,  suitable  for  all  operations,  giving  complete  instructions 

regarding  necessary  preparation  of  patient,  etc.,  with  a  full  list  of  dressings  and 
medicines  to  be  employed. 

At  the  back  of  pad  is  a  list  of  instruments  used — viz.  general  instruments, 
etc.,  required  for  all  operations;  and  special  mstruments  for  surgery  of  the 
brain  and  sj^me,  mouth  and  throat,  abdomen,  rectum,  male  and  female  genito 
urinary  organs,  the  lx)nes,  etc. 

The  whole  forming  a  neat  pad,  arranged  for  hanging  on  the  wall  of  a  sur 
geon's  office  or  in  the  hospital  operatmg-room. 

"  Will  serve  a  useful  purpose  for  the  surgeon  in  reminding  him  of  the  details  of  prepa- 
ration for  the  patient  and  the  room  as  well  as  for  the  instruments,  dressings,  and  antiseptics 
needed  " — New  York  Medical  Record 

"  Covers  about  all  that  can  be  needed  in  any  operation." — American  Lancet. 

"  The  plan  is  a  capital  one." — Boston  Medical  and  Surgical  Journal. 


ESSENTIALS  OF  ANATOMY  AND  MANUAL  OF  PRACTI- 
CAL DISSECTION,  containing  "  Hints  on  Dissection  "  By  Charles 
B.  Nancrede,  M.  D.,  Professor  of  Surgery  and  Clinical  Surgery  in  the 
University  of  Michigan,  Ann  Arbor ;  Corresponding  Member  of  the  Royal 
Academy  of  Medicine,  Rome,  Italy;  late  Surgeon  Jefferson  Medical  Col- 
lege, etc.  Fourth  and  revised  edition.  Post  8vo,  over  500  pages,  with 
handsome  full-page  lithographic  plates  in  colors,  and  over  200  illustrations. 
Price  :  Extra  Cloth  or  Oilcloth  for  the  dissection-room,  $2.00  net. 

Neither  pains  nor  expense  has  been  spared  to  make  this  work  the  most  ex- 
haustive yet  concise  Student's  Manual  of  Anatomy  and  Dissection  ever  pub- 
lished, either  in  America  or  in  Europe. 

The  colored  plates  are  designed  to  aid  the  student  in  dissecting  the  muscles, 
arteries,  veins,  and  nerves.  The  wood-cuts  have  all  been  specially  drawn  and 
engraved,  and  an  Appendix  added  containing  60  illustrations  representing  the 
structure  of  the  entire  human  skeleton,  the  whole  being  based  on  the  eleventh 
edition  of  Gray's  Anafo/ny,  and  forming  a  handsome  post  8vo  volume  of  over 
500  pages. 

"  The  plates  are  of  more  than  ordinary  excellence,  and  are  of  especial  value  to  students  in 
their  work  in  the  dissecting-room.  "^/<?«r«rt/  of  American  Medical  Association. 

"  Should  be  in  the  hands  of  every  medical  student." — Cleveland  Medical  Gazette. 

"  A  concise  and  judicious  work." — Buffalo  Medical  and  Surgical  Journal. 


CATALOGUE    OF  MEDICAL    WORKS.  IJ 


A  MANUAL  OF  PRACTICE  OF  MEDICINE.  By  A.  A.  Stevens, 
A.  M.,  M.  Dm  Instructor  of  Physical  Diagnosis  in  the  University  of  Penn- 
sylvania, and  Demonstrator  of  Pathology  in  the  Woman's  Medical  College 
of  Philadelphia.  Specially  intended  for  students  preparing  for  graduation 
and  hospital  examinations,  and  includes  the  following  sections :  General 
Diseases,  Diseases  of  the  Digestive  Organs,  Diseases  of  the  Respiratory 
System,  Diseases  of  the  Circulatory  System,  Diseases  of  the  Nervous  Sys- 
tem, Diseases  of  the  Blood,  Diseases  of  the  Kidneys,  and  Diseases  of  the 
Skin.  Each  section  is  prefaced  by  a  chapter  on  General  Symptomatology. 
Third  edition.  Post  8vo,  502  pages.  Numerous  illustrations  and  selected 
formulae.     Price,  S2.50. 

Contributions  to  the  science  of  medicine  have  poured  in  so  rapidly  during  the 
last  quarter  of  a  century  that  it  is  well-nigh  impossible  for  the  student,  with  the 
hmited  time  at  his  disix)sal,  to  master  elaborate  treatises  or  to  cull  from  them 
that  knowledge  which  is  absolutely  essential.  From  an  extended  experience  in 
teaching,  the  author  has  been  enabled,  by  classification,  to  group  allied  symp- 
toms, and  by  the  judicious  elimination  of  theories  and  redundant  explanations 
to  bring  within  a  comparatively  small  compass  a  complete  outline  of  the  prac- 
tice of  medicine. 

A  SYLLABUS  OF  LECTURES  ON  THE  PRACTICE  OF  SUR- 
GERY, arranged  in  conformity  with  The  American  Text-Book  of 
Surgery.  By  Nicholas  Senn,  M.  D.,  Ph.  D.,  Professor  of  Surgery  in 
Rush  Medical  College,  Chicago,  and  in  the  Chicago  Polyclinic.  Price, 
j^2.oo. 

This,  the  latest  work  of  its  eminent  author,  himself  one  of  the  contributors 
to  the  "American  Text  Book  of  Surgery,"  will  prove  of  exceptional  value  to 
the  advanced  student  who  has  adopted  that  work  as  his  text-book.  It  is  not 
only  the  syllabus  of  an  unrivalled  course  of  surgical  practice,  but  it  is  also  an 
epitome  or  supplement  to  the  larger  work. 

SYLLABUS  OF  OBSTETRICAL  LECTURES  in  the  Medical 
Department,  University  of  Pennsylvania.  By  Richard  C.  Norris, 
A.  M.,  M.  D.,  Demonstrator  of  Obstetrics  in  the  University  of  Pennsyl- 
vania. Third  edition,  thoroughly  revised  and  enlarged.  Crown  8vo. 
Price,  Cloth,  interleaved  for  notes,  $2.00  net. 

"  This  work  is  so  far  superior  to  others  on  the  same  subject  that  we  take  pleasure  in  call- 
ing attention  briefly  to  its  excellent  features.  It  covers  the  subject  thoroughly,  and  will 
prove  invaluable  both  to  the  student  and  the  practitioner.  The  author  has  introduced  a 
number  of  valuable  hints  which  would  only  occur  to  one  who  was  himself  an  experienced 
teacher  of  obstetrics.  The  subject-matter  is  clear,  forcible,  and  modern.  We  are  especially 
pleased  with  the  portion  devoted  to  the  practical  duties  of  the  accoucheur,  care  of  the  child, 
etc.  The  paragraphs  on  antiseptics  are  admirable;  there  is  no  doubtful  tone  in  the  direc- 
tions given.  No  details  are  regarded  as  unimportant;  no  minor  matters  omitted.  We  ven- 
ture to  say  that  even  the  old  practitioner  will  find  useful  hints  in  this  direction  which  he  can- 
not afford  to  despise." — New  York  Medical  Record. 


1 8  fV.   B.   SAUNDERS' 


OUTLINES  OF  OBSTETRICS:  A  Syllabus  of  Lectures  Deliv- 
ered at  Long  Island  College  Hospital.  By  Charles  J evvett,  A.  M,, 
M.  D.,  I'rufessoi"  of  Obstetrics  and  Pediatrics  in  the  College,  and  Obstetri- 
cian to  the  Hospital.  Edited  by  Harold  F.  Jkwett,  M.D.  Post  8vo, 
264  pages.     Price,  $2.00. 

This  book  treats  only  of  the  general  facts  and  principles  of  obstetrics  :  these 
are  stated  in  concise  terms  and  in  a  systematic  and  natural  order  of  sequence, 
theoretical  discussion  being  as  far  as  possible  avoided;  the  subject  is  thus 
presented  in  a  form  most  easily  grasped  and  remembered  by  the  student. 
Special  attention  has  been  devoted  to  ])ractical  cjuestions  of  diagnosis  and 
treatment,  and  in  general  particular  prominence  is  given  to  facts  which  the  stu- 
dent most  needs  to  know.  The  condensed  form  of  statement  and  the  orderly 
arrangement  of  topics  adapt  it  to  the  wants  of  the  busy  practitioner  as  a  means 
of  refreshing  his  knowledge  of  the  subject  and  as  a  handy  manual  for  daily 
reference. 

NOTES  ON  THE  NEWER  REMEDIES:  their  Therapeutic  Ap- 
plications and  Modes  of  Administration.  By  iJAVin  Cerna,  M.  D., 
Ph.  D.,  Demonstrator  of  and  Lecturer  on  Experimental  Therapeutics  in 
the  University  of  Pennsylvania.     Post-octavo,  175  pages.     Price,  ^1.25. 

The  work  takes  up  in  alphabetical  order  all  the  newer  remedies,  giving  their 
physical  properties,  solubility,  therapeutic  applications,  administration,  and 
chemical  formula. 

It  thus  forms  a  very  valuable  addition  to  the  various  works  on  therapeutics 
now  in  existence. 

Chemists  are  so  multiplying  compounds,  that,  if  each  compound  is  to  be  thor- 
oughly studied,  investigations  must  be  carried  far  enough  to  determine  the  prac- 
tical importance  of  the  new  agents. 

"Especially  valuable  because  of  its  completeness,  its  accuracy,  its  systematic  consider- 
ation of  the  properties  and  therapy  of  many  remedies  of  which  doctors  generally  know  but 
little,  expressed  in  a  brief  yet  terse  manner." — Chicago  Clinical  Re-niew. 

"A  timely  and  needful  book  ....  which  physicians  who  avail  themselves  of  the  use  of 
the  newer  remedies  cannot  afford  to  do  without." — The  Sanitarian. 

LABORATORY  EXERCISES  IN  BOTANY.  By  Edson  S.  Bastin, 
M.  A.,  Professor  of  Materia  Medica  and  Botany  in  the  Philadelphia  Col- 
lege of  Pharmacy.     With  over  75  plates.     (In  preparation.) 

This  work  is  intended  for  the  beginner  and  the  advanced  student,  and  it  fully 
covers  the  structure  of  flowering  plants,  roots,  ordinary  stems,  rhizomes,  tubers, 
bulbs,  leaves,  flowers,  fruits,  and  seeds.  Particular  attention  is  given  to  the  gross 
and  microscopical  structure  of  plants,  and  to  those  used  in  medicine.  Illustra- 
tions have  freely  been  used  to  elucidate  the  text,  and  a  complete  index  to  facil- 
itate reference  has  been  added. 

The  folding  charts  which  supplement  the  subjects  will  be  found  useful  in 
connection  with  the  study  of  the  text. 


CATALOGUE    OF  MEDICAL    WORKS.  1 9 


SAUNDERS'  POCKET  MEDICAL  LEXICON;  or,   Dictionary  of 

Terms  and  Words  used  in  Medicine  and  Surgery.  By  John  M. 
Keating,  M.  D.,  editor  of  "  Cyclopaedia  of  Diseases  of  Children,"  elc. ; 
author  of  the  "New  Pronouncing  Dictionaiy  of  Medicine;  and  Henry 
Hamilton,  author  of  "  A  New  Translation  of  Virgil's  ^'Eneid  into  Eng- 
lish Verse;"  co-nuthor  of  a  "  New  Pronouncing  Dictionaiy  of  Medicine." 
A  new  and  revised  edition.  32010,  282  pages.  Prices:  Cloth,  75  cents; 
Leather  Tucks,  $1.00. 

This  new  and  comprehensive  work  of  reference  is  the  outcome  of  a  demand 
for  a  more  modern  handbook  of  its  class  than  those  at  present  on  the  market, 
which,  dating  as  they  do  from  1855  ^o  1884,  are  of  but  trifling  use  to  the  student 
by  their  not  containing  the  hundreds  of  new  v\  ords  now  used  in  current  litera- 
ture, especially  those  relating  to  Electricity  and  Bacteriology. 

"  Remarkably  accurate  in  terminology,  accentuation,  and  dAivvuxwr^.." —Journal  of  Amer- 
ican Medical  Association. 

"  Brief,  yet  complete  ....  it  contains  the  very  latest  nomenclature  in  even  the  newest 
departments  of  medicine." — AVrt'  Y'ork  Medical  Record. 


SAUNDERS'  POCKET  MEDICAL  FORMULARY.  By  William 
M.  Powell,  M.  D.,  Attending  Physician  to  the  Mercer  House  for  Invalid 
Women  at  Atlantic  City.  Containing  1750  Formulae,  selected  from  several 
hundred  of  the  best-known  authorities.  Forming  a  handsome  and  con- 
venient pocket  companion  of  nearly  300  printed  pages,  with  blank  leaves 
for  Additions ;  with  an  Appendix  containing  Posological  Table,  Formulae 
and  Doses  for  Hypodermatic  Medication,  Poisons  and  their  Antidotes, 
Diameters  of  the  Pemale  Pelvis  and  Foetal  Head,  Obstetrical  Table,  Diet 
List  for  Various  Diseases,  Materials  and  Drugs  used  in  Antiseptic  Surger\', 
Treatment  of  Asphyxia  from  Drowning,  Surgical  Remembrancer,  Tables 
of  Incompatibles,  Eruptive  Fevers,  Weights  and  Measures,  etc.  Third 
edition,  revised  and  greatly  enlarged.  Handsomely  bound  in  morocco, 
with  side  index,  wallet,  and  flap.     Price,  $1.75  net. 

A  concise,  clear,  and  correct  record  of  the  many  hundreds  of  famous  formula? 
which  are  found  scattered  through  the  works  of  the  7nost  efniutnt physicians 
a tid surgeons  of  the  world.  The  work  is  helpful  to  the  student  and  practitioner 
alike,  as  through  it  they  become  acquainted  with  numerous  formulce  which  are 
not  found  in  text-books,  but  have  been  collected  from  among  the  rising getiera- 
tion  of  the  profession,  college  professors,  and  hospital  physicians  and  surgeons. 

"This  little  book,  that  can  be  conveniently  carried  in  the  pocket,  contains  an  immense 
amount  of  material.  It  is  ver\-  useful,  and  as  the  name  of  the  author  of  each  prescription  is 
given  is  unusually  reliable." — Xe70  VorA  Medical  Record. 

"  Designed  to  be  of  immense  help  to  the  general  practitioner  in  the  exercise  of  his  daily 
calling." — Boston  Medical  and  Surgical  Jourtial. 


20  W.   B.   SAUNDERS' 


HOW    TO    EXAMINE    FOR    LIFE  INSURANCE.     By  John   M. 

Kka'IINC,  M.  D.,  Fellow  of  the  College  of  Physicians  and  Surgeons  of 
Philadelphia;  Vice-President  of  the  American  Pediatric  Society;  Ex- 
President  of  the  Association  of  Life  Insurance  Medical  Directors.  Royal 
8vo,  211  pages,  with  two  large  phototype  illustrations,  and  a  plate  pre- 
,  pared  by  Dr,  McClellan  from  special  dissections ;  also,  numerous  cuts  to 
elucidate  the  text.     Second  edition.     Price,  in  Cloth,  $2.00  net. 

Part  I.,  which  has  been  carefully  prepared  from  the  best  works  on  Physical 
Diagnosis,  is  a  short  and  succinct  account  of  the  methods  used  to  make 
examinations  ;  a  description  of  the  normal  condition  and  of  the  earliest 
evidences  of  disease. 

Part  II.  contains  the  Instructions  of  twenty-four  Life  Insurance  Companies  to 
their  medical  examiners. 

"This  is  by  far  the  most  useful  book  which  has  yet  appeared  on  insurance  examination,  a 
subject  of  growing  interest  and  importance.  Not  the  least  valuable  portion  of  the  volume  is 
Part  II.,  which  consists  of  instructions  issued  to  their  examining  physicians  by  twenty-four 
representative  companies  of  this  country.  As  the  proofs  of  these  instructions  were  corrected 
by  the  directors  of  the  companies,  thej'  form  the  latest  instructions  oljtainable.  If  for  these 
alone,  the  book  should  be  at  the  right  hand  of  every  physician  interested  in  this  special  branch 
of  medical  science." — The  Medical  Neivs,  Philadelphia. 


MANUAL  OF  MATERIA  MEDICA  AND  THERAPEUTICS. 

By  A.  A.  Sfevens,  A.  M.,  M.  D.,  Instructor  of  Physical  Diagnosis  in  the 
University  of  Pennsylvania,  and  Demonstrator  of  Pathology  in  the  Woman's 
Medical  College  of  Philadelphia.     435  pages.     Price,  Cloth,  ^2.25. 

This  wholly  new  volume,  which  is  based  on  the  1890  edition  of  the  Pharma- 
copceia,  comprehends  the  following  sections  :  Physiological  Action  of  Drugs ; 
Drugs;  Remedial  Mea.sures  other  than  Drugs;  Applied  Therapeutics;  Incom- 
patibility in  Prescriptions;  Table  of  Doses;  Index  of  Drugs;  and  Index  of 
Diseases ;  the  treatment  being  elucidated  by  more  than  two  hundred  formulae. 

"The  author  is  to  be  congratulated  upon  having  presented  the  medical  student  with  as 
accurate  a  manual  of  therapeutics  as  it  is  possible  to  \,r&\i^r&."  —Therapeutic  Gazette. 

"  Far  superior  to  most  of  its  class  ;  in  fact,  it  is  very  good.  Moreover,  the  book  is  reliable 
and  accurate."— A'^^y  York  Medical  Journal. 

"The  author  has  faithfully  presented  modern  therapeutics  in  a  comprehensive  work,  .  .  . 
and  it  will  be  found  a  reliable  guide." — University  Medical  Magazine. 

"Will  be  of  immense  service  to  the  busy  Y>r3^c\.\t\onG.r."  —Medical  Reporter  (Calcutta). 

"  Reliable  and  timt\y."  — North  American  Practitioner. 

"Concise,  up  to  date,  and  withal  comprehensive." — Pacific  Medical  Journal. 


SAUNDERS'  QUESTION  COMPENDS. 

Arranged  in  Question  and  Answer  Form. 

THE  LATEST,  CHEAPEST,  and  BEST  ILLUSTRATED 
SERIES  OF  COMPENDS  EVER  ISSUED. 


Now  the  Standard  Authorities  in  Medical  Literature 


WITH 


Students  and  Practitioners  in  every  City  of  the  United 
States  and  Canada. 


THE    REASON    WHY. 

They  are  the  advance  guard  of  '•  Student's  Helps  " — that  DO  help  ;  they  are 
the  leaders  in  their  special  line,  uiell  and  authoritatively  ivritte7i  by  able  f?ien, 
who^  as  teachers  in  the  large  colleges,  knoio  exactly  zvhat  is  wanted  by  a  student 
preparing  for  his  examinations.  The  judgment  exercised  in  the  selection  of 
authors  is  fully  demonstrated  by  their  professional  elevation.  Chosen  from  the 
ranks  of  Demonstrators,  Quiz-masters,  and  Assistants,  most  of  them  have  be- 
come Professors  and  Lecturers  in  their  respective  colleges. 

Each  book  is  of  convenient  size  (5x7  inches),  containing  on  an  average  250 
pages,  profusely  illustrated,  and  elegantly  printed  in  clear,  readable  t\^e,  on 
fine  paper. 

The  entire  series,  numbering  twenty- four  subjects,  has  been  kept  thoroughly 
revised  and  enlarged  when  necessaiy,  many  of  them  being  in  their  fourth  and 
fifth  editions. 

TO   SUM   UP. 

Although  there  are  numerous  other  Quizzes,  Manuals,  Aids,  etc.  in  the  mar- 
ket, none  of  them  approach  the  "  Blue  Series  of  Question  Compends;"  and 
the  claim  is  made  for  the  following  points  of  excellence  : 

1.  Professional  distinction  and  reputation  of  authors. 

2.  Conciseness,  clearness,  and  soundness  of  treatment. 

3.  Size  of  type  and  quality  of  paper  and  binding. 

*^*  Any  of  these  Compends  will  be  mailed  on  receipt  of  price. 

21 


22  J^V.    B.   SAUNDERS' 


I.  ESSENTIALS  OF  PHYSIOLOGY.  By  H.  A.  Hark,  M.  D.,  Pro- 
fessor of  Therapeutics  and  Materia  Medica  in  the  Jefferson  Medical  Col- 
lej^e  of  Philadelphia;  Physician  to  St.  Agnes'  Hospital  and  to  the  Medical 
Dispensary  of  the  Children's  Hospital;  Laureate  of  the  Royal  Academy 
of  Medicine  in  Belgium,  of  the  Medical  Society  of  London,  etc.  Third 
edition,  revised  and  enlarged  by  the  addition  of  a  series  of  handsome 
plate  illustrations  taken  from  the  celebrated  "  Icones  Nervorum  Capitis'' 
of  Arnold.  Crown  8vo,  230  pages,  numerous  illustrations.  Price,  Cloth, 
^i.oo  net;  interleaved  for  notes,  $1.25  net. 

"An  exceedingly  useful  little  compend.  The  author  has  done  his  work  thoroughly  and 
well.  The  plates  of  the  cranial  nerves  from  Arnold  are  superb." — Journal  of  American 
Medical  Association. 


2.  ESSENTIALS    OF    SURGERY,  containing  also  Venereal    Diseases, 

Surgical  Landmarks,  Minor  and  Operative  Surgery,  and  a  Complete  De- 
scription, together  with  full  Illustrations,  of  the  Handkerchief  and  Roller 
Bandages.  By  Edward  Martin,  A.M.,  M.D.,  Clinical  Professor  of 
Genito-Urinary  Diseases,  Instructor  in  Operative  Surgery,  and  Lecturer  on 
Minor  Surgery,  University  of  Pennsylvania;  Surgeon  to  the  Howard  Hos- 
pital ;  Assistant  Surgeon  to  the  University  Hospital,  etc.  Fifth  edition. 
Crown  8vo,  334  pages,  profusely  illustrated.  Considerably  enlarged  by 
an  Appendix  containing  full  directions  and  prescriptions  for  the  prepara- 
tion of  the  various  materials  used  in  Antiseptic  Surgery ;  also  several 
hundred  recipes  covering  the  medical  treatment  of  surgical  affections. 
Price,  Cloth,  ^i.oo;  interleaved  for  notes,  $1.25. 

"Written  to  assist  the  student,  it  will  be  of  undoubted  value  to  the  practitioner,  contain- 
ing as  it  does  the  essence  of  surgical  work." — Boston  Medical  and  Sjirgical  Journal. 

"  Cleverly  combines  all  the  merits  of  condensation,  while  avoiding  the  errors  of  super- 
ficiality and  inaccuracy." — Univcj-sity  Medical  Magazine. 

3.  ESSENTIALS    OF    ANATOMY,  including  the  Anatomy  of  the 

"Viscera.  By  Charles  B.  Nancrede,  M.  D.,  Professor  of  Surgery  and 
of  Clinical  Surgery  in  the  University  of  Michigan,  Ann  Arbor;  Cor- 
responding Member  of  the  Royal  Academy  of  Medicine,  Rome,  Italy ; 
late  Surgeon  to  the  Jefferson  Medical  College,  etc.  Fifth  edition.  Crown 
8vo,  380  pages,  180  illustrations.  Enlarged  by  an  Appendix  containing 
over  sixty  illustrations  of  the  Osteology  of  the  Human  Body.  The  whole 
based  upon  the  last  (eleventh)  edition  of  Gray's  Anatomy.  Price,  Cloth, 
^i.oo;  interleaved  for  notes,  $1.25. 

"  Truly  such  a  book  as  no  student  can  afford  to  be  without." — American  Practitioner 
and  Neivs. 

"  The  questions  have  been  wisely  selected    and  the  answers  accurately  and  concisely 
given." — University  Medical  Magazine. 


CATALOGUE   OF  MEDICAL    WORKS.  23 


4.  ESSENTIALS  OF  MEDICAL  CHEMISTRY,  ORGANIC  AND 

INORGANIC,  containing  also  Questions  on  Medical  Physics,  Chemical 
Physiology,  Analytical  Processes,  Urinalysis,  and  Toxicology.  By  Law- 
rence Wolff,  M  D.,  Demonstrator  of  Chemistry,  Jefferson  Medical  Col- 
lege;  Visiting  Physician  to  the  German  Hospital  of  Philadelphia;  Member 
pf  Philadelphia  College  of  Pharmacy,  etc.  Fourth  and  revised  edition, 
with  an  Appendix.  Crown  8vo,  212  pages.  Price,  Cloth,  $1.00;  inter- 
leaved for  notes,  $1.25. 

"  The  scope  of  this  work  is  certainly  equal  to  that  of  the  best  course  of  lectures  on  Med- 
ical Chemistry." — Pharmaceutical  Era. 

"  We  could  wish  that  more  books  like  this  would  be  written,  in  order  that  medical  students 
might  thus  early  become  interested  in  what  is  often  a  difficult  and  uninteresting  branch  of 
medical  study." — Medical  and  Surgical  Reporter. 

5.  ESSENTIALS    OF    OBSTETRICS.      By  W.   Easterly   Ashton, 

M.  D.,  Professor  of  Gynecology  in  the  Medico-Chirurgical  College  of 
Philadelphia;  Obstetrician  to  the  Philadelphia  Hospital.  Third  edition, 
thoroughly  revised  and  enlarged.  Crown  8vo,  244  pages,  75  illustrations. 
Price,  Cloth,  $1.00  ;  interleaved  for  notes,  $1.25. 

"  An  excellent  little  volume  containing  correct  and  practical  knowledge.  An  admirable 
compend,  and  the  best  condensation  we  have  seen." — Southern  Practitioner. 

"Of  extreme  value,  to  students,  and  an  excellent  little  book  to  freshen  up  the  memory  of 
the  practitioner." — Chicago  Medical  Times. 

6.  ESSENTIALS    OF    PATHOLOGY    AND    MORBID    ANAT- 

OMY. By  C.  E.  Armand  Semple,  B.  A.,  M.  B.,  Cantab.  L.  S.  A., 
M.  R.  C.  P.  Lond.,  Physician  to  the  Northeastern  Hospital  for  Children, 
Hackney;  Professor  of  Vocal  and  Aural  Physiology  and  Examiner  in 
Acoustics  at  Trinity  College,  London,  etc.  Crown  8vo,  174  pages,  illus- 
trated.    Sixth  thousand.    Price,  Cloth,  $r.oo;  interleaved  for  notes,  $1.25. 

"A  valuable  little  volume — truly  a  vtultuin  in  parvo." — Cincinnati  Medical  Ne7vs. 

"The  volume  is  very  comprehensive,  covering  the  entire  field  of  pathology." — St.  Joseph 
Medical  Herald. 

7.  ESSENTIALS    OF    MATERIA    MEDICA,    THERAPEUTICS, 

AND  PRESCRIPTION-WRITING.  By  Henry  Morris,  M.  D., 
late  Demonstrator,  Jefferson  Medical  College;  Fellow  of  the  College  of 
Physicians,  Philadelphia;  co-editor  Biddle's  Materia  Medica;  Visiting 
Physician  to  St.  Joseph's  Hospital,  etc.  Fourth  edition.  Crown  Svo,  250 
pages.     Price,  Cloth,  $1.00;  interleaved  for  notes,  $1.25. 

"One  of  the  best  compends  in  this  series.  Concise,  pithy,  and  clear,  well  suited  to  the 
purpose  for  which  it  is  prepared." — Aledical  and  Surgical  Reporter. 

"  The  subjects  are  treated  in  such  a  unique  and  attractive  manner  that  they  cannot  fail  to 
impress  the  mind  and  instruct  in  a  lasting  manner." — Buffalo  Medical  and  Surgical  yournal. 


24  ^^    B.    SAUNDERS' 


8,  9.  ESSENTIALS   OF   PRACTICE   OF   MEDICINE.     By  Hknry 

Mdkris,  M.  1).,  autlior  of  "  Essentials  of  Materia  Medica,"  etc.,  with  an 
A}ij)endix  on  the  CHnical  and  INIicroscopical  Kxamination  of  Urine,  by 
Lawrknck  WoLKi",  M.  D.,  author  of  "  Essentials  of  Medical  Chemistry," 
etc.  Colored  (Vogel)  urine  scale  and  numerous  hue  illustrations.  Third 
edition,  enlarged  by  some  three  hundred  essential  formulae,  selected  from 
the  writings  of  the  most  eminent  authorities  of  the  medical  profession, 
collected  and  arranged  by  William  M.  Powell,  M.  D.,  author  of 
"  Essentials  of  Diseases  of  Children."  Crown  8vo,  460  pages.  Price, 
Cloth,  ^2.00. 

"  The  teaching  is  sound,  the  presentation  graphic,  matter  as  full  as  might  be  desired,  and 
the  style  attractive." — American  Practitioner  atid  News. 

"A  first-class  practice  of  medicine  boiled  down,  and  giving  the  real  essentials  in  as  few 
words  as  is  consistent  with  a  thorough  understanding  of  the  subject." — Medical  Brief. 

"  Especially  full,  and  an  excellent  illustration  of  what  the  best  of  the  compends  can  be 
made  to  be." — Gaillanf  s  Medical  Journal. 


10.  ESSENTIALS  OF  GYNAECOLOGY.  By  Edwin  B.  Cragin, 
M.  D.,  Attending  Gynaecologist,  Roosevelt  Hospital,  Out-Patients'  Depart- 
ment; Assistant  Surgeon,  New  York  Cancer  Hospital,  etc.  Fourth  edi- 
tion, revised.  Crown  8vo,  198  pages,  62  fine  illustrations.  Price,  Cloth, 
$1.00;  interleaved  for  notes,  $1.25. 

"  This  is  a  most  excellent  addition  to  this  series  of  question  compends.  The  style  is  con- 
cise, and  at  the  same  time  the  sentences  are  well  rounded.  This  renders  the  book  far  more 
easy  to  read  than  most  compends,  and  adds  distinctly  to  its  value." — Medical  and  Surgical 
Reporter. 

"  Useful  not  only  to  the  student  who  is  barely  at  the  threshold  of  professional  life,  but  to 
the  busy  practitioner  as  well." — Ne-iU  York  Medical  yournal. 


II.  ESSENTIALS  OF  DISEASES  OF  THE  SKIN.  By  Henry  W. 
Stelwagon,  M.  D.,  Clinical  Lecturer  on  Dermatology  in  the  Jefferson 
Medical  College,  Philadelphia;  Physician  to  the  Skin  Service  of  the 
Northern  Dispensary ;  Dermatologist  to  Philadelphia  Hospital ;  Physician 
to  Skin  Department  of  the  Howard  Hospital ;  Clinical  Professor  of  Der- 
matology in  the  Woman's  Medical  College,  Philadelphia,  etc.  Third  edi- 
tion. Crown  8vo,  270  pages,  86  illustrations,  many  of  which  are  original. 
Price,  Cloth,  $1  00 ;  interleaved  for  notes,  $1.25  net. 

"  An  immense  amount  of  literature  has  been  gone  over  and  judiciously  condensed  by  the 
writer's  skill  and  experience." — New  York  Medical  Record. 

"  The  book  admirably  answers  the  purpose  for  which  it  is  written.     The  experience  of  the 
reviewer  has  taught  him  that  just  such  a  book  is  needed." — New  York  Medical  Journal . 


CATALOGUE    OF  MEDICAL    WORKS.  2$ 


12.   ESSENTIALS  OF  MINOR  SURGERY,  BANDAGING,  AND 
VENEREAL  DISEASES.      By  Edward   Martin,   A.M.,   M.  D., 

author  of  "  Esseniials  of  Surgery,"  etc.  Second  edition.  Crown  8vo, 
thoroughly  revised  and  enlarged,  78  illustrations.  Price,  Cloth,  $1.00; 
interleaved  for  notes,  $1.25. 

"Characterized  by  the  same  literary  excellence  that  has  distinguished  previous  numbers 
of  this  series  of  compends." — American  Practitioner  and  Neivs. 

"  The  best  condensation  of  the  subjects  of  which  it  treats   yet  placed  before  the  pro- 
fession."—J/tv/iVrt/  Nezvs,  Philadelphia. 

"  A  capital  little  book.     The  illustrations  are  remarkably  clear  and  intelligible." — Aus- 
trali.in  Medical  Gazette. 

"  We  have  nothing  but  praise  for  the  subject-matter  of  this  hook."— Bristoi  Medico-Chi- 
rurgical  Journal. 


13.  ESSENTIALS  OF  LEGAL  MEDICINE,  TOXICOLOGY, 
AND  HYGIENE.  By  C.  E.  Armand  Semple,  M.  D.,  author  of  "  Es- 
sentials of  Pathology  and  Morbid  Anatomy."  Crown  8vo,  212  pages, 
130  illustrations.     Price,  Cloth,  $1.00;  interleaved  for  notes,  $1.25. 

"  The  leading  points,  the  essentials  of  this  too  much  neglected  portion  of  medical  science, 
are  here  summed  up  systematically  and  clearly  " — Southern  Practitioner. 

"  But  for  the  author's  judicious  condensation  of  facts,  the  information  it  contains  would  be 
sufficient  to  fill  an  ordinary  octavo  volume." — College  and  Clinical  Record. 


14.  ESSENTIALS  OF  REFRACTION  AND  DISEASES  OF 
THE  EYE.  By  EinvARD  Jackson,  A.M.,  M.  D.,  Professor  of  Dis- 
eases of  the  Eye  in  the  Philadelphia  Polyclinic  and  College  for  Graduates 
in  Medicine;  Member  of  the  American  Ophthalmological  Society;  Fel- 
low of  the  College  of  Physicians  of  Philadelphia  ;  Fellow  of  the  American 
Academy  of  Medicine,  etc. ;  and  ESSENTIALS  OF  DISEASES  OF 
THE  NOSE  AND  THROAT.  By  E.  Baldwin  Gleason,  S.  B., 
M.  D.,  Clinical  Professor  of  Otology,  Medico-Chirurgical  College,  Phila- 
delphia ;  Surgeon  in  charge  of  the  Nose,  Throat,  and  Ear  Department  of 
the  Northern  Dispensary  of  Philadelphia ;  formerly  Assistant  in  the  Nose 
and  Throat  Dispensary  of  the  Hospital  of  the  University  of  Pennsylvania, 
and  Assistant  in  the  Nose  and  Throat  Department  of  the  Union  Dispen- 
sary, etc.  Two  volumes  in  one.  Second  edition.  Crown  8vo,  294  pages, 
124  illustrations.     Price,  Cloth,  $1.00;  interleaved  for  notes.  Si. 25. 

"A  valuable  book  to  the  beginner  in  these  branches,  to  the  student,  to  the  busy  prac- 
titioner, and  as  an  adjunct  to  more  thorough  reading.  The  authors  are  capable  men,  and  as 
successful  teachers,  know  what  a  student  most  needs." — Neio  York  Medical  Record. 

"  Verj'  valuable,  since  in  both  sections  is  given  about  all  that  a  candidate  for  examination 
is  required  to  know." — Medical  Times  and  Hospital  Gazette. 


26  JV.    B.    SAUNDERS' 


15.  ESSENTIALS  OF  DISEASES  OF  CHILDREN.    By  William 

M.  rowELL,  M.  D.,  Atlciulintj;  I'hysician  to  the  Mciccr  House  for  Invalid 
Women  at  Atlantic  City,  N.J.;  late  Physician  to  the  Clinic  for  the  Dis- 
eases of  Children  in  the  Hospital  of  the  University  of  Pennsylvania  and 
St.  Clement's  Hospital ;  Instructor  in  Physical  Diagnosis  in  the  Medical 
Department  of  the  University  of  Pennsylvania.  Crown  8vo,  216  jiages. 
Price,  Cloth,  $1.00 ;  interleaved  for  notes,  ^1.25. 

"  This  work  is  gotten  up  in  the  clear  and  attractive  style  that  characterizes  the  Saunders 
Series.  It  contains  in  appropriate  form  the  gist  of  all  the  best  works  in  the  department  to 
which  it  relates." — American  Practitioner  and  News. 

"  The  book  contains  a  series  of  important  questions  and  answers,  which  the  student  will 
find  of  great  utility  in  the  examination  of  children." — Annals  of  Gynecology. 

16.  ESSENTIALS  OF  EXAMINATION  OF  URINE.  By  Law 
RENCE  Wolff,  M.  D.,  author  of  "  Essentials  of  Medical  Chemistry,"  etc. 
Colored  (Vogel)  urine  scale  and  numerous  illustrations.  Crown  8vo. 
Price,  Cloth,  75  cents. 

"  A  little  work  of  decided  value." — University  Medical  Magazine . 

"  A  good  manual  for  students,  well  written,  and  answers,  categorically,  many  questions 
beginners  are  sure  to  ask." — Neiv  York  Medical  Record. 

"  The  questions  have  been  well  chosen,  and  the  answers  are  clear  and  brief.  The  book 
cannot  fail  to  be  useful  to  students." — Medical  and  Surgical  Reporter . 

17.  ESSENTIALS    OF    DIAGNOSIS.      By   Solomon   Solis-Cohen, 

M.  D.,  Professor  of  Clinical  Medicine  and  Applied  Therapeutics  in  the 

Philadelphia  Polyclinic,  and  Augustus  A.  Eshner,  M.  D.,  Instructor  in 

Clinical  Medicine,  Jefferson  Medical  College,  Philadelphia.     Crown  8vo, 

382  pages,  55  illustrations,  some  of  which  are  colored,  and  a  frontispiece. 

Price,  $1.50  net. 

"A  good  book  for  the  student,  properly  written  from  their  standpoint,  and  confines  itself 
well  to  its  text." — New  York  Medical  Record. 

"Concise  in  the  treatment  of  the  subject,  terse  in  expression  of  fact.  .  .  .  The  work  is 
reliable,  and  represents  the  accepted  views  of  clinicians  of  to-day." — American  Journal  0/ 
Medical  Sciences. 

"The  subjects  are  explained  in  a  few  well-selected  words,  and  the  required  ground  has 
been  thoroughly  gone  over." — International  Medical  Magazine. 

18.  ESSENTIALS  OF  PRACTICE  OF  PHARMACY.  By  Lucius 
E.  Sayre,  M.  D.,  Professor  of  Pharmacy  and  Materia  Medica  in  the  Uni- 
versity of  Kansas.  Second  edition,  revised  and  enlarged.  Crown  8vo, 
200  pages.     Price,  Cloth,  ^i.oo;  interleaved  for  notes,  ^1.25. 

"Covers  a  great  deal  of  ground  in  small  compass.  The  matter  is  well  digested  and 
arranged.  The  research  questions  are  a  valuable  feature  of  the  book." — Albany  Medical 
Annals. 

"  The  best  quiz  on  Pharmacy  we  have  yet  examined." — National  Drtig  Register. 

"  The  veteran  pharmacist  can  peruse  it  with  pleasure,  because  it  emphasizes  his  grasp 
upon  knowledge  already  gleaned." — IVestern  Drug  Record. 


CATALOGUE    OF  MEDICAL    WORKS.  2/ 


20.  ESSENTIALS  OF  BACTERIOLOGY:  A  Concise  and  Syste- 
matic Introduction  to  the  Study  of  Micro-organisms.  By  M.  V. 
Ball,  M.  D.,  Assistant  in  Microscopy,  Niai^ara  University,  Buffalo,  N.  Y. ; 
late  Resident  Physician,  German  Hospital,  Philadelphia,  etc.  Second  edi- 
tion, revised.     Crown  8vo,  200  pages,  81  illustrations,  some  in  colors,  and 

•5  plates.     Price,  Cloth,  Si. 00;  interleaved  for  notes,  ^1.25. 

"  The  amount  of  material  condensed  in  this  little  book  is  so  great,  and  so  accurate  are 
the  formulae  and  methods,  that  it  will  be  found  useful  as  a  laboratory  handbook." — Medical 
News. 

"  Bacteriology  is  the  keynote  of  future  medicine,  and  every  physician  who  expects  success 
must  familiarize  himself  with  a  knowledge  of  germ-life — the  agents  of  disease.  This  little 
book,  with  its  beautiful  illustrations,  will  give  the  students,  in  brief,  the  results  of  years  of 
study,  and  research  unaided."— Pac/yic  Record  of  Medicine  and  Surgery. 

"Thoroughly  practical,  very  concise,  clear,  well-written,  and  sufficiently  illustrated.  .  .  . 
The  best  book  of  the  kind  in  the  English  language." — Medical  and  Surgical  Reporter. 

21.  ESSENTIALS  OF  NERVOUS  DISEASES  AND  INSANITY, 
their  Symptoms  and  Treatment.  By  John  C.  Shaw,  jSI.  D.,  Clinical 
Professor  of  Diseases  of  the  Mind  and  Nervous  System,  Long  Island  Col- 
lege Hospital  Medical  School ;  Consulting  Neurologist  to  St.  Catherine's 

Hospital  and  to  the  Long  Island  College  Hospital ;  formerly  Medical  Super- 
intendent King's  County  Insane  Asylum.  Second  edition.  Crown  Svo,  186 
pages,  48  original  illustrations,  mostly  selected  from  the  Author's  private 
practice.     Price,  Cloth,  $1.00;   interleaved  for  notes,  ^1.25. 

"  Clearly  and  intelligently  -wrxitGn." —Boston  Medical  and  Surgical  yournal. 

"A  valuable  addition  to  this  series  of  compends,  and  one  that  cannot  fail  to  be  appreciated 
by  all  physicians  and  students." — Medical  Brief. 

"  Dr.  Shaw's  Primer  is  e.xcellent.  The  engravings  are  well  e.xecuted  and  very  interest- 
ing."— Medical  Times  and  Register. 

"  Written  with  great  clearness,  devoid  of  verbosity,  it  encompasses  in  a  brief  space  a  vast 
amount  of  valuable  information." — Pacific  Medical  Record. 

22.  ESSENTIALS  OF  PHYSICS.  By  Fred  J.  Brockway,  M.  D., 
Assistant  Demonstrator  of  Anatomy  in  the  College  of  Physicians  and  Sur- 
geons, New  York.  Second  edition.  Crown  8vo,  320  pages,  155  fine  illus- 
trations.    Price,  Cloth,  $1.00  net;  interleaved  for  notes,  ^1.25  net. 

The  publisher  has  again  shown  himself  as  fortunate  in  his  editor  as  he  ever  has  been  in 
the  attractive  style  and  make-up  of  his  compends."— .-^wz^r/caw  Practitioner  and  News. 

"Conlams  all  that  one  need  know  of  the  subject,  is  well  written,  and  is  copiouslv  il'us- 
X.XAX^d."—Ne7v  York  Medical  Record. 

"  The  author  has  dealt  with  the  subject  in  a  manner  that  will  make  the  theme  not  only 
comparatively  easy,  but  also  of  int^r^sx.."— Medical  News,  Philadelphia. 

"  Deserving  of  close  investigation  at  the  hands  of  students  and  ^hys\c\2ins." —American 
gynecological  journal. 


28  fV.   B.   SAUNDE/^S'    CATALOGUE. 

23.    ESSENTIALS     OF    MEDICAL    ELECTRICITY.     By    D.    D. 

Stewart,  M.  D.,  Demonstrator  of  Diseases  of  the  Nervous  System  and 
Chief  of  the  Neurological  Clinic  in  the  Jefferson  Medical  College  ;  Phy- 
sician to  St.  Mary's  Hospital  and  to  St.  Christopher's  Hospital  for  Chil- 
dren, etc. ;  and  E.  S.  Lawranck,  M.  D.,  Chief  of  the  Electrical  Clinic, 
and  Assistant  Demonstrator  of  Diseases  of  the  Nervous  System  in  the 
Jefferson  Medical  College,  etc.  Crown  8vo,  I48  pages,  65  illustrations. 
Price,  Cloth,  $1.00;  interleaved  for  notes,  ^1.25. 

"  Clearly  written,  and  affords  a  safe  guide  to  the  beginner  in  this  subject." — Boston  Med- 
ical and  Surgical  Journal. 

"The  subject  is  presented  in  a  lucid  and  pleasing  manner." — New  York  Medical  Record. 

"  A  little  work  on  an  important  subject,  which  will  prove  of  great  value  to  medical  students 
and  trained  nurses  who  wish  to  study  the  scientific  as  well  as  the  practical  points  of  elec- 
tricity."—  '/Vie  Hospital,  London. 

"  The  selection  and  arrangement  of  material  are  done  in  a  skilful  manner.  It  gives,  in  a 
condensed  form,  the  principles  and  science  of  electricity  and  their  application  in  the  practice 
of  medicine." — Annals  of  Surgery. 

"  The  compilation  is  a  good  one,  and  will  be  found  useful  both  to  students  and  to  men  in 
practice." — JVezv  Zealand  Medical  Journal. 


24.    ESSENTIALS    OF    DISEASES    OF    THE    EAR.     By  E.  B. 

Gleasox,  S.  B.,  M.  D.,  Clinical  Professor  of  Otology,  Medico-Chirurgical 
College,  Philadelphia;  Surgeon  in  Charge  of  the  Nose,  Throat,  and  Ear 
Department  of  the  Northern  Dispensary  of  Philadelphia;  formerly  As- 
sistant in  the  Nose  and  Throat  Dispensary  of  the  Hospital  of  the  Univer- 
sity of  Pennsylvania,  and  Assistant  in  the  Nose  and  Throat  Department 
of  the  Union  Dispensary.  89  illustrations.  Price,  Cloth,  $1.00 ;  inter- 
leaved for  notes,  $1.25. 

This  latest  addition  to  the  Saunders  Compend  Series  accurately  represents 
the  modern  aspect  of  otological  science.  The  effort  has  been  made  to  state  the 
Essentials  of  Otology  concisely,  without  sacrificing  accuracy  to  brevity,  and  the 
book,  while  small  in  compass,  is  logically  and  capably  written;  it  comprises  up- 
ward of  150  pages,  with  89  illustrations,  most  of  which  are  from  original 
sources. 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsi.stx) 

RD31D11C.1 

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